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NEW YORK STATE DEPARTMENT OF HEALTH OFFICE OF HEALTH INSURANCE PROGRAMS Enrolled/Patient Request for Specific Medicaid Protected Health Information Federal regulations permit you to request a specific
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How to fill out enrolleepatient request for specific
How to fill out an enrollee/patient request for specific?
01
Start by filling out your personal information accurately. This includes your full name, address, contact number, and any other required details.
02
Next, provide your insurance information. This may include your policy number, group or individual plan details, and any other relevant information requested.
03
Clearly state the reason for your request. Be specific and concise in explaining the type of service or treatment you require. Include any supporting documentation or medical records, if applicable.
04
If you have a preferred healthcare provider or facility, mention it in the request. Include their contact information and any specific instructions regarding the provider or facility.
05
Make sure to sign and date the request form. This serves as your authorization for the release of information and your agreement to the terms and conditions set by your insurance provider.
Who needs an enrollee/patient request for specific?
01
Individuals who want to receive healthcare services or treatment that may require pre-authorization or specific approval from their insurance provider.
02
Patients who want to visit a specific healthcare provider or facility that may not be in their insurance network.
03
Enrollees who plan to receive non-standard or specialized medical treatments/services that may require additional documentation or approval from their insurance provider.
Remember, it is always recommended to review the specific instructions and requirements provided by your insurance company before filling out the enrollee/patient request for specific.
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