Cape Cod Healthcare DPO Medical Plan MEDICAL EXCEPTION FORM 2026

1. Click ‘Get Form’ to open the Cape Cod Healthcare DPO Medical Plan MEDICAL EXCEPTION FORM in the editor.
2. Begin by filling out the 'Patient Information' section. Enter the patient's name, date of birth, address, city, state, ZIP code, phone number, and Tufts Member ID.
3. Next, complete the 'Primary Care Provider Information' section. Indicate whether the PCP is a DPO provider by circling 'Yes' or 'No', then provide the PCP's name and contact details.
4. In the 'Provider or Facility You Are Requesting Exception For' section, select the type of service needed by circling one of the options: Office Visit, Lab Services, or Radiology/Imaging. Fill in the provider/facility name and other required details.
5. Provide a reason for your request in the 'Reason for Request' section. Be sure to include any relevant information about previous visits or recommendations from specialists.
6. Finally, sign and date the form at the bottom to authorize forwarding this information if necessary.

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