In Lieu Of Step 1 of 3 33% Member InformationEnter Member Id and Date of Birth to validate Member before proceeding with the form.Member's ID#* Member's DOB* MM slash DD slash YYYY Date of Service (if known) MM slash DD slash YYYY Name* First Last Error Message Provider InformationRendering Provider's Name/Group NPI* 10 digitsRendering Provider's Name/Group Name* Error Message Ordering MD* Ordering MD phone #*Ordering MD Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Clinical InformationDiagnosis (Click + or - at the right to add up to 5 Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890CPT Code(s) (Click + or - at the right to add more CPT Codes)*CPT CodeUnits Example CPT code: 12345By checking the box and signing below, you are attesting that these In Lieu of Services are an alternative to services which Neighborhood Health Plan of RI provides for members as medically appropriate therapy.Please choose service being requested*Please choose service being requested *Chiropractic Services in lieu of medications or invasive procedures for chronic painAcupuncture Services in lieu of medications or invasive procedures for chronic painMassage Therapy in lieu of medication or invasive procedures for chronic painAttach Clinical* Drop files here or Select files Accepted file types: pdf, doc, docx, Max. file size: 10 MB, Max. files: 10. Upload only PDF or Word DocumentSignature of Treating Physician or licensed provider*Signature Date:* Request Method*Request Method *StandardExpedited: By checking Expedited, you are stating that processing this request in the standard time (14 days) for making a determination could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function. Please attach documentation that supports the need for an Expedited decision. Also please note that a request with a date of service in the past cannot be considered as Expedited.Attach additional Clinical documents for Expedited request*Accepted file types: pdf, doc, docx, Max. file size: 13 MB.Upload only PDF or Word DocumentsSignature of Physician or Licensed Provider (Required for Expedited request)*Signature Date:* CommentsAuthorization is not a guarantee of paymentCAPTCHA