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Submit an off-list hospital request

Practitioner name

Please give the name of the person providing the service

Email address

Contact name

Please give the name of the person filling in the form

Hospital or proposed hospital name

Patient's plan number

Patient's name

Patient's date of birth

Day

Month

Year

Claim number

Yes, the member consents

Please confirm member consent

Procedure codes

If supplying multiple procedure codes, please separate with a comma

Max character limit reached /

Procedure/Treatment date

Reason for request

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Supporting documents

Please upload any supporting clinical information for the request

You can upload a maximum of 5 files
Acceptable file formats include: PDF, JPG, PNG, XLS, XLSX, DOC and DOCX
Maximum file size must not exceed 5MB

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