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Get Bcbs Of Mn Payer Id 2018-2024

Explanation including diagnosis code(s) why member is being referred beyond state guidelines: Name of Clinic/Facility being Referred to: Referred Clinic/Facility Address: Date Span of Referral: Note: Attach medical records that support medical necessity and reason for travel beyond state guidelines. Primary Care Doctor can be Physician, Nurse Practitioner, Clinical Nurse Specialist or Physician Assistant. Please provide the details requested above and return this form by fax to 1-855-933-6992.

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