Cape Cod Healthcare Inc - Full Filing- Nonprofit Explorer 2026

1. Click ‘Get Form’ to open it 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, Tufts Member ID, and email address.
3. Next, provide details in the 'Primary Care Provider Information' section. Indicate if the PCP is a DPO provider by circling 'Yes' or 'No', then enter the PCP's name, phone number, and fax number.
4. In the 'Facility You Are Requesting Exception For' section, select the type of service (Lab Services or Radiology/Imaging), and fill in the facility name, hospital/surgical center details, dates of service, NPI numbers, address, and contact information.
5. Answer whether you have previously been seen at this facility and provide the date if applicable. Then move to the 'Reason for Request' section and select or describe your reason for requesting an exception.
6. Finally, authorize the forwarding of information by signing and dating at the bottom of the form. Ensure all required fields are completed before submission.

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