Health Plan Out-of-Network Referral Request Form

Health Plan Out-of-Network Referral Request Form
Request approval to see an out-of-network provider. Please complete all sections accurately.
Patient/Member Full Name
First NameLast Name
Patient/Member Date of Birth
MonthDayYear
Date
Insurance Plan Name
Member ID (do not enter full government ID)
Requesting Provider Name
Requesting Provider Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Out-of-Network Provider Name
Requested Service or Procedure
Diagnosis or Relevant Condition (do not include sensitive medical information)
Reason for Out-of-Network Referral
Should be Empty: