01. Edit your outpatient behavioral network exception request form online
Type text, add images, blackout confidential details, add comments, highlights and more.
Evernorth Outpatient Behavioral Network Exception Request Form 2026
Here's how it works
02. Sign it in a few clicks
Draw your signature, type it, upload its image, or use your mobile device as a signature pad.
03. Share your form with others
Send evernorth network exception request via email, link, or fax. You can also download it, export it or print it out.
How to use or fill out Evernorth Outpatient Behavioral Network Exception Request Form with DocHub
Ease of Setup
DocHub User Ratings on G2
Ease of Use
DocHub User Ratings on G2
- Click ‘Get Form’ to open the Evernorth Outpatient Behavioral Network Exception Request Form in our editor.
- Begin by filling in the 'Requested Start Date of Network Exception' section. Indicate whether treatment has started and provide the start date if applicable.
- Complete the customer information fields, including name, date of birth, and member ID. Ensure all details are accurate for processing.
- In the 'Outpatient Provider' section, enter your name, degree(s), license information, and contact details. Confirm if voicemail is confidential.
- List the diagnosis codes (F codes) and requested CPT codes relevant to the treatment. Specify the location of services as either home or office.
- Provide a detailed clinical rationale for requesting the network exception, explaining why your treatment specialties are uniquely suited for this customer.
- Finally, sign and date the form, then save it to your computer. Email it to NER@Evernorth.com or fax it to 860-687-7329.
Start using our platform today to streamline your form completion process for free!
See more outpatient behavioral network exception request form versions
We've got more versions of the outpatient behavioral network exception request form form. Select the right outpatient behavioral network exception request form version from the list and start editing it straight away!
Security and compliance
At DocHub, your data security is our priority. We follow HIPAA, SOC2, GDPR, and other standards, so you can work on your documents with confidence.
network exception request form
If you use a non-Duke behavioral health provider, please confirm that provider participates in the Evernorth (Cigna) Behavioral Health Network. Print Guide.Read more
Dec 31, 2022 DOCUMENTS INCORPORATED BY REFERENCE. Part III of this Form 10-K incorporates by reference information from the registrants definitive proxyRead more