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WEBPKS-0091-17 May 2017 For requests beyond the yearly preset limits or every 6 months for concurrent requests include an updated treatment plan and progress summary. Amerigroup Sunflower United Fax 800-505-1193 Fax 866-694-3649 Fax 855-268-9392 Autism Authorization Request Form Please print clearly incomplete or illegible forms will delay processing. Date Member Name DOB Address SSN Medicaid ID Other Primary Insurance Check AGENCY or PROVIDER to indicate how to authorize services...
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