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<table border="0" cellspacing="0" cellpadding="0"> <tr> <td colspan="2" width="581" align="left"> <img src="/images/header/member/outNetwork.gif" height="105" width="557" border="0" alt="Out-of-Network Claims"> </td> </tr> <tr> <td width="31"><img src="/images/pixel.gif" alt="space" width="31" height="21"></td> <td rowspan="2" valign="top"> <table width="558" border="0" cellspacing="0" cellpadding="1"> <tr> <td><img src="/images/pixel.gif" alt="space" width="1" height="3"></td> </tr> <tr> <td><span class="HeaderText">&nbsp;</span></td> </tr> </table> <img src="/images/pixel.gif" alt="space" width="525" height="1"> </td> </tr> <tr> <td width="31"><img src="/images/pixel.gif" alt="space" width="1" height="36"></td> </tr> </table>
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If you are an MHN member using out-of-network benefits, or a practitioner treating a member who is using out-of-network benefits, you may submit claims using a CMS (HCFA)-1500 form.

Please read the following instructions carefully when completing this form.
 
  CMS (HCFA)-1500 Instructions
 
     
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