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Medical prior authorization form
Fax completed form to: 877.974.4411 toll-free, or 616.942.8206
This form applies to:
This request is:Commercial Individual (PACA)
Urgent (life-threatening)
Monument
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What is requesting physician?
Requesting physician is the healthcare provider who orders a specific medical service or treatment for a patient.
Who is required to file requesting physician?
The healthcare facility or provider performing the requested service is required to file the requesting physician.
How to fill out requesting physician?
The requesting physician form typically includes the name, contact information, and medical license number of the healthcare provider who ordered the service.
What is the purpose of requesting physician?
The purpose of requesting physician is to ensure proper documentation and communication between healthcare providers regarding the requested medical service.
What information must be reported on requesting physician?
The requesting physician form must include the date of the request, the reason for the request, and any relevant medical history of the patient.
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