Get the free FAX this completed form to 866-399-0929 - Superior HealthPlan

MEDICATION PRIOR AUTHORIZATION REQUEST FORM Superior Health Plan, TEXAS (Do Not Use This Form for Biopharmaceutical Products*) FAX this completed form to 866-399-0929 OR Mail requests to: US Script

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9. Once you have filled out the form completely, review it one final time to ensure nothing is missing or incomplete. Verify that you have signed and dated the document if required.
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Remember, it's essential to follow the instructions carefully, provide accurate information, and ensure the timely and secure transmission of the faxed form.

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You can fill out the form either electronically or by hand, following the instructions provided on the form.

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The purpose of faxing this completed form is to provide the required information to the recipient in a timely manner.

What information must be reported on fax this completed form?

The specific information that must be reported on the form will be outlined in the form instructions.

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