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11/11/2015 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID AZ88 This fax machine is located in a secure location as required by HIPAA regulations. Gynecologist or obstetrician formulary hormonal cycle control agent such as ethinyl plus ethinyl plus or ethinyl plus medroxyprogesterone or Please indicate which medication s patient tried If yes skip to question 18. Complete/review information sign and date. Fax signed forms to Mercy Maricopa Integrated Care - TXIX/XXI...
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