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NEBRASKA MEDICAID PROGRAM REQUEST FOR PRIOR AUTHORIZATION OF PAYMENT GROWTH HORMONE (GH) FOR CHILDREN PRESCRIBING PROVIDER: MEDICAID RECIPIENT: Name: Name: First Last Phone #: () Medicaid #: Fax #:

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How to fill out prescribing provider

How to fill out prescribing provider:

01

Start by entering the full name of the prescribing provider. This includes their first name, middle initial (if applicable), and last name.

02

Next, input the provider's unique identification number. This could be a National Provider Identifier (NPI) or any other identifying number specific to the provider. This helps to ensure that the correct provider is being identified.

03

Include the contact information of the prescribing provider. This typically includes their phone number, email address, and office address. This information is important for communication purposes and for any necessary follow-up.

04

Indicate the provider's specialty or area of expertise. This is especially important for cases where a specific type of medication or treatment is required. It helps to ensure that the prescribing provider has the necessary knowledge and qualifications.

05

Specify the provider's license or certification information. This includes the state in which they are licensed and their license number. It is important to accurately input this information to confirm the provider's legitimacy and adherence to regulations.

Who needs a prescribing provider:

01

Patients who require prescription medications or treatments from a healthcare professional. A prescribing provider is necessary to accurately assess the patient's condition and prescribe the appropriate medication.

02

Individuals seeking medical guidance or advice. A prescribing provider can offer expert recommendations, guidance, and treatment options based on their medical knowledge and expertise.

03

Patients with chronic conditions or complex medical needs. These individuals often require ongoing care and regular consultations with a prescribing provider to manage their condition effectively.

In summary, filling out the prescribing provider involves entering their personal details, contact information, professional credentials, and expertise. Patients in need of prescription medications or medical guidance generally require a prescribing provider to meet their healthcare needs.

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