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PharmacyName: Pharmacy NPI: PhoneNumber: Number: Page 1 of 2 *ForPharmacyUseONLY* PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: Inland Empire Health Plan/Medical Group
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New pa universalform v3 is the latest version of the Pennsylvania Universal Form for reporting certain tax information.
All individuals and entities that meet the filing requirements set by Pennsylvania tax authorities are required to file new pa universalform v3.
To fill out new pa universalform v3, individuals and entities must provide the requested tax information in the designated sections of the form and submit it by the deadline.
The purpose of new pa universalform v3 is to collect and report certain tax information to the Pennsylvania tax authorities for regulatory and assessment purposes.
Information such as income, deductions, credits, and other relevant tax data must be reported on new pa universalform v3.
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