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/ Kombiglyze XR / / JentaduetoURGENT24 HORROR AUTHORIZATION REQUEST FORM Complete ENTIRE form and Fax to: 8669407328SECTION A PATIENT INFORMATION Today's Date: Member ID #: City: Phone: Primary Insurance:First
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Urgent-24 hour is a reporting requirement that must be submitted within 24 hours for urgent matters.
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Individuals or organizations involved in urgent matters are required to file urgent-24 hour.
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The purpose of urgent-24 hour is to ensure timely reporting of urgent matters for immediate action.
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The information reported on urgent-24 hour must include details of the urgent matter, parties involved, and any actions taken or required.
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