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Prereview Cover Sheet Prior Authorization Request Form This form is a rearview cover sheet only. Please also complete and attach any drug specific forms available. Complete this entire form and fax

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What is re-review cover sheet?

Re-review cover sheet is a document used to request a review of a decision that has already been made.

Who is required to file re-review cover sheet?

Any individual or organization who wishes to challenge a decision and request a review is required to file a re-review cover sheet.

How to fill out re-review cover sheet?

The re-review cover sheet must be completed with relevant information such as the original decision being challenged, reasons for the challenge, and any supporting documents.

What is the purpose of re-review cover sheet?

The purpose of re-review cover sheet is to allow individuals or organizations to challenge a decision and request a review.

What information must be reported on re-review cover sheet?

The re-review cover sheet must include details of the original decision being challenged, reasons for the challenge, and any supporting documents.

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