Network Exemption

Membership Number (required)

Patient's Name (required)

Patient's Date of Birth (required)

Provider Name (required)

Provider Number (required)

Contact email (required)

Contact Number (required)

Contact's name (required)

Procedure Code(s) (required)

Date of Procedure (required)

Proposed Hospital Name (required)

Further Information

Supporting documents

If you need to upload more than one document, please upload your files here

Relevant document 2

Relevant document 3

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Relevant document 5

Please tick here to confirm you have consent to share the member's details*

Please tick here to confirm this has been discussed with the Network Hospital (required)

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