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FAX Completed Form To 8669407328Request for Prior Authorization SHORT ACTING OPIOIDS IA Medicaid Member ID #(PLEASE PRINT ACCURACY IS IMPORTANT) Patient anterior Authorization 8003106826 Patient address
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The completed form should be faxed to the designated fax number.
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The form should be filed by the individual or entity specified in the instructions.
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The form should be completed with accurate information and then faxed to the appropriate recipient.
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