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Prior Authorization Request Form Fax Back To: (866× 9407328 Phone: (800× 3106826 Specialty Medication Prior Authorization Cover Sheet (This cover sheet should be submitted along with a Pharmacy
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This patient has a medical condition requiring treatment.
The patient's healthcare provider is required to file the information.
The form can be filled out by providing detailed information about the patient's medical condition.
The purpose is to ensure proper treatment and care for the patient.
Information such as diagnosis, treatment plan, and any relevant medical history must be reported.
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