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PRIOR AUTHORIZATION REQUEST FORM Complete ENTIRE form and Fax to 866-940-7328 Today s Date SECTION A - PATIENT INFORMATION First Name Address City Phone Primary Insurance Last Name Member ID State DOB Policy Zip Allergies Group or a CONTINUATION of THERAPY If so start date Is this patient currently hospitalized Yes No Is the requested medication NEW SECTION B - PHYSICIAN INFORMATION Fax Office Contact Name / Fax Attention to SECTION C...
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What is 866 940 7328?
866 940 7328 is the form number for reporting certain information to the IRS.
Who is required to file 866 940 7328?
Employers are required to file 866 940 7328 if they have certain reportable transactions.
How to fill out 866 940 7328?
866 940 7328 must be filled out accurately and completely, providing all required information as per the instructions provided by the IRS.
What is the purpose of 866 940 7328?
The purpose of 866 940 7328 is to report specific information to the IRS for tax compliance purposes.
What information must be reported on 866 940 7328?
Certain reportable transactions and information related to those transactions must be reported on 866 940 7328.
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