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OUT OF PLAN REFERRAL WORKSHEET Phone Number: Toll free at (800) 8912520 or (419) 8872520 Fax Number: 5676610847 or Toll Free: 8442824907 Attention: Outflank CoordinatorDate of Request: Member Name:DOB
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Fax20request-form-outofplan-referralpdf is needed by individuals who are seeking out-of-plan referrals for medical services that are not covered by their insurance provider. It can be used by patients, healthcare providers, or insurance company representatives who are responsible for processing referral requests.
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fax20request-form-outofplan-referralpdf is a form used to request out-of-plan referral for certain services or procedures.
Patients who are seeking services or procedures that are not covered under their current plan may be required to file fax20request-form-outofplan-referralpdf.
fax20request-form-outofplan-referralpdf should be completed with the patient's personal information, details of the requested service or procedure, and any relevant medical documentation.
The purpose of fax20request-form-outofplan-referralpdf is to request authorization for out-of-plan services or procedures.
fax20request-form-outofplan-referralpdf must include the patient's name, date of birth, insurance information, requested service or procedure, reason for out-of-plan referral, and any supporting medical documentation.
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