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Submit an off-list hospital request

Please give the name of the person providing the service

Please give the name of the person filling in the form

Yes, the member consents

If supplying multiple procedure codes, please separate with a comma

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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