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The expiration date specifies the length of time the service is authorized. Requested Referral Status Number of Visits Please indicate whether the referral is for a second opinion. Yes Start Date Expiration Date Requested No. Umpqua Health Alliance PRIOR AUTHORIZATION FORM A Coordinated Care Organization Referrals Phone 541 672 1685 Fax 541 677 5881 RUSH patient s health at immediate risk PRINT FORM Print Form PAYMENT FOR ALL SERVICES IS SUBJECT TO CONFIRMATION that the beneficiary is...

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