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OUTPATIENT TREATMENT REQUEST FORM Please print clearly incomplete or illegible forms will delay processing. PROVIDER INFORMATION MEMBER Name Provider Name (print) Health Plan Provider/Agency Tax ID

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Please print clearly incomplete is a phrase used to indicate that the information being provided should be written in a legible and clear manner.

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Anyone who is submitting a form or document that requires information to be filled out is required to ensure it is printed clearly and legibly.

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