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State File Ins. Co. File Date of Injury MEDICAL EVIDENCE FOR PRE-AUTHORIZATION REQUEST 1. Explain the reason and medical necessity for the proposed treatment attach additional pages if needed 2. Explain how the proposed treatment is related to the patient s work injury attach additional pages if needed Signature of Physician/Health Care Provider Date Name of Physician/Health Care Provider Practice Name.
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What is 1 explain form reason?
1 explain form reason is a form used to provide an explanation or reason for a specific situation or action.
Who is required to file 1 explain form reason?
Individuals or entities who need to provide an explanation or reason for a particular matter are required to file 1 explain form reason.
How to fill out 1 explain form reason?
To fill out 1 explain form reason, you will need to provide detailed information about the situation or action that requires an explanation. This may include dates, relevant facts, and any supporting documentation.
What is the purpose of 1 explain form reason?
The purpose of 1 explain form reason is to allow individuals or entities to provide a clear and concise explanation for a specific matter, which may help in resolving issues or conflicts.
What information must be reported on 1 explain form reason?
On 1 explain form reason, you must report all relevant information related to the situation or action that requires an explanation, including any supporting documentation.
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