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Plan Name: NYS Medicaid FeeForServicePlan Phone No.(877)3099493Plan Fax No. (800)2682990Website: https://newyork.fhsc.com/providers/PDP about. Assays Medicaid Prior Authorization Request Form For
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The images for the given link are documents related to a Medicaid prior authorization form.
Healthcare providers or facilities requesting Medicaid coverage for a specific service or treatment are required to file these images.
The form must be completed with all relevant patient and treatment information, signed by the healthcare provider, and submitted to the Medicaid office.
The purpose of these images is to request approval from Medicaid for a specific medical service or treatment.
Patient details, healthcare provider information, treatment needed, justification for the treatment, and any supporting medical documentation must be reported on the form.
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