Out Of Network Request Form Step 1 of 3 33% Please return completed form to the Utilization Department at 401-459-6023 Please refer to Neighborhood’s Clinical Medical Policy which is available on our Neighborhood web site, www.nhpri.org for more detailed information about this benefit, authorization requirements, and coverage criteria. Please remember: An authorization for services is not guarantee of payment. Important Information for Payment: W-9 Forms are required in order to get reimbursed by Neighborhood for authorized services. If this has not previously been sent, please submit with this request. 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* MM slash DD slash YYYY Name* First Last Error Message Organizational InformationReferring Provider Name* Referring Provider Phone #*Referring Provider Fax #*Organizational NPI* Out of Network Organizational Name* Error Message Place of Service* Address for Remittance Advice/Payment* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Treating Practitioner Name* Treating Practitioner NPI* Specialty Type* Phone #*Fax #*Contact Name* Email address in order to receive confirmation of request receipt* Previous Auth Number Clinical InformationPlease Attach Clinical Notes* 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 DocumentPrimary Diagnosis (Click + or - at the right to add additional Diagnoses)*DiagnosisICD 10 Diagnosis Code Example ICD 10 Diag Code: Z87.890CPT and/or HCPC Code(s) (Click + or - at the right to add additional codes)*Code TypeCodeUnits Example CPT code: 12345 Example HCPC code: S1234 with modifier: S1234 U1Any Medication/Pharmaceuticals associated with this request?*Any Medication/Pharmaceuticals associated with this request? *YesNoIf yes, please list*Purpose For RequestPurpose For Request* New Consult Follow up consult Second Opinion Consult Imaging Lab/Pathology Inpatient (Elective Admission) Other check all that applyReason Has Member already been evaluated by an In-Network NHPRI Specialist*Has Member already been evaluated by an In-Network NHPRI Specialist *YesNoIf yes, please provide specialty*If yes, please provide specialty *PCPSpecialistName of Specialist* Phone # of Specialist*Reason for Out of Network referral and supporting documentation from In Network Provider attached?*Reason for Out of Network referral and supporting documentation from In Network Provider attached? *YesNo*It is expected that imaging, lab, pathology, and therapy services will be performed in Neighborhood’s Network with the results sent to the primary care provider, unless otherwise authorized. *Neighborhood has partnered with Evicore for prior authorization of all outpatient elective MRI, CT, NCM/MPI and PET studies. Please visit Evicore’s web site for more information www.evicore.com.Signature of 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