Out of Network Forms

Use this form if you have a Blue Cross and Blue Shield MN plan.

This includes Medicare replacement plans.

Use this form if you have a Health Partners plan.

Use this form if you have a Medica plan. You will also need a printed out CMS 1500 form which we will provide for you.

This includes Medicare replacement plans.

Use this form if you have a United Health Care plan.

Use this form if you have a Humana plan.

This includes Medicare replacement plans.

Use this form if you have a BCBS Anthem plan.

This includes anyone working at Graphic Packaging.