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05/20/2015 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID This fax machine is located in a secure location as required by HIPAA regulations. Complete/review information sign and date. Fax signed forms to Mercy Maricopa Integrated Care - TXIX/XXI SMI at 1-855-247-3677. Please contact Mercy Maricopa Integrated Care - TXIX/XXI SMI at 1-800-564-5465 with questions regarding the Prior Authorization process. 2. Does the patient have a history of a spontaneous preterm...

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How to fill out when conditions are met

1. Start by identifying the specific conditions that need to be met in order to proceed.
2. Gather all the necessary information and documentation required for filling out the form.
3. Carefully read through the instructions provided on the form to ensure a thorough understanding of the requirements.
4. Begin filling out the form by entering the requested information accurately and legibly.
5. Follow any specific guidelines or formatting instructions provided on the form.
6. Double-check all the entered information for accuracy and completeness.
7. Review any additional documents or attachments that need to be submitted along with the form.
8. Make sure to meet any deadlines or submission requirements specified on the form.
9. Once the form is completely filled out, sign and date it as required.
10. Submit the form along with any supporting documents through the designated channel or to the appropriate authority.
11. Keep a copy of the filled-out form and any submitted documents for your records.

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