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Get the Note All necessary ancillary supplies are provided free of charge to the patient at the t...

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Prior Authorization Request Form Fax Back To: 1-800-853-3844 Phone: 1-800-711-4555 5 AM 7 PM PT M-F or visit www.OptumRx.com and click Health Care Professionals for online real-time submission 24/7
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Note all necessary ancillary is a specific form or document required to provide additional information or details.
Any individual or entity who has relevant information or details that need to be included in the ancillary document.
The ancillary document can be filled out manually or electronically, following the provided instructions and guidelines.
The purpose of the ancillary document is to ensure all relevant information is disclosed and included for proper documentation.
All pertinent details, data, or explanations that are relevant to the main document or form being submitted.
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