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Texas Referral/Authorization Form Please fill out form completely in blue or black ink. Refer to instruction sheet. Certification/authorization guidelines must be followed. Provider name Specialty type Provider/Facility Provider City Texas REFERRED TO LOCATION Office Outpatient facility Inpatient 23 Hour observation Note for outpatient facility List CPT4 at right ER/Post Stabilization Other Date of service // Facility name Facility COMMENT...
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