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NON-PARTICIPATING PROVIDER REFERRAL FORM NEIGHBORHOOD HEALTH PARTNERSHIP Fax completed form with pertinent clinical information to 800-731-2515 Please be advised, failure to comply with Utilization

How to fill out non-participating provider referral form

How to fill out a non-participating provider referral form:

1. Obtain the form: Contact your insurance company or download the non-participating provider referral form from their website.
2. Personal information: Fill in your personal details, including your name, date of birth, address, and contact information.
3. Insurance information: Provide your insurance policy number, group number, and any other relevant information requested.
4. Provider details: Include the name, specialty, and contact information of the non-participating provider you wish to see.
5. Reason for referral: State the reason why you need to see a non-participating provider and provide any supporting documentation if required.
6. Urgency and preferred appointment time: Indicate the urgency of your referral and if you have a preferred date or time for your appointment.
7. Authorization and signature: Read the authorization statement carefully and sign the form to acknowledge your understanding and agreement.
8. Submit the form: Send the completed form to your insurance company according to their instructions, either by mail, fax, or online submission.

Who needs a non-participating provider referral form:

1. Individuals with out-of-network coverage: Non-participating provider referral forms are typically required for individuals who have out-of-network benefits as part of their insurance coverage.
2. Seeking specialized care: These forms are commonly used when individuals need to see a specialist or healthcare provider who is not within their insurance network.
3. Second opinions or alternative treatments: Non-participating provider referral forms may also be necessary for individuals seeking second opinions or alternative treatments that are not offered by in-network providers.

For pdfFiller’s FAQs

What is non-participating provider referral form?

Non-participating provider referral form is a document used to refer a patient to a healthcare provider who does not participate in a particular insurance plan's network.

Who is required to file non-participating provider referral form?

The referring healthcare provider or the patient may be required to file the non-participating provider referral form, depending on the insurance plan's requirements.

How to fill out non-participating provider referral form?

To fill out a non-participating provider referral form, one must provide the patient's information, reason for the referral, the non-participating provider's contact information, and any other required details.

What is the purpose of non-participating provider referral form?

The purpose of the non-participating provider referral form is to authorize a patient's visit to a healthcare provider who is not in the insurance plan's network.

What information must be reported on non-participating provider referral form?

The non-participating provider referral form typically requires information such as the patient's name, insurance information, reason for the referral, and the non-participating provider's contact details.

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