Medical Plan Out-of-Area Request Form

Medical Plan Out-of-Area Request Form

You will be notified of a decision, by email, within 5 business days of this form being received by HR Benefits.

Click here to access the Benefits Guide

Questions? Contact HR Benefits at benefits@hendrickhealth.org or call 325-670-3163

Employee ID*

Employee First Name*

Employee Last Name*

Preferred Email*

Preferred Phone Number

Date of Birth or UMR Member ID#*

Assigned Hospital Campus*

Select or enter value

Out-of-Area/"Allowed" Network Request

I hereby request access to the UnitedHealthcare "Allowed" network, at Hendrick Health "Preferred" network rates.

I understand this access may be granted to me and my covered dependent(s), if applicable, only if I, the employee of Hendrick, work or live 60 or more miles away from my assigned Hendrick campus, which includes Hendrick Medical Center North, Hendrick Medical Center South, Hendrick Health Service Center and Hendrick Medical Center Brownwood.

(Dependent children may have access to the UnitedHealthcare "Allowed" network at Hendrick Health "Preferred" network rates if the child(ren) reside outside of your home and live 60 or more miles away from your assigned hospital campus. If the request applies to child(ren) only, please contact UMR beginning January 1, 2024.

60+ Mile Rule: Address Option*

Select the address section for which the 60+ mile rule applies.

Select or enter value

60+ Mile Rule: Address Detail*

List the Address, City, State and Zip for the address selected in the question above.

Employee Signature*

My electronic signature is the same as my written signature.

Type your first and last name as your electronic signature.

Confirmation

We highly recommend checking the box "Send me a copy of my responses" for confirmation your submission was successful.

Send me a copy of my responses

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