Form 4091c 04043 - Out Of Network Outpatient Prior Authorization Page 2

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Out-of-network Outpatient
Prior Authorization Request Form
Fax to: 888-977-0776
Additional information
Have you previously treated this Network Health member?
Yes
No
/
/
/
/
If yes, specify dates. From
to
Did the Network Health member seek treatment for the requested sessions with an in-network provider(s)?
Yes
No
If yes, describe the outcome.
Do you offer cultural, linguistic, or other communication services that the member requires?
Yes
No
If yes, please specify.
Does the member require treatment in a language, other than English, that you provide?
Yes
No
If yes, please specify.
Does the member require any special services, other than communication services, that you provide?
Yes
No
If yes, please specify.
List any additional information to support your out-of-network outpatient prior authorization request.
List the referral source.
/
/
/
/
Number of sessions requested
Date range for sessions from
to
Form available at
Phone: 888-257-1985
4091C 04043
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