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PM FORM 10. 1. 6 REQUEST FOR OUT-OF-HOME ADMISSION OOH CHILD/ADULT Attachment to INPATIENT/OUTPATIENT Prior Authorization Form or Portal Request Date of Request TYPE OF SERVICE REQUESTED BHRF non BIP non SUD HCTC BHTH BHIF-RTC Name of Person Completing Request Health Home Requesting Facility Staff Email Staff Phone/Ext Staff Fax Submit completed typed form as attachment to applicable prior authorization form i.e. inpatient or outpatient via Secure fax to 1-866-601-0111 or as an attachment to...
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Start by gathering all the necessary information about the child or adult you are filling out the form for.
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Childadult refers to a document or form used to report information about dependents, such as children or adult dependents, for tax or insurance purposes.
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