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HEALTH PARTNERS PLANS PRIOR AUTHORIZATION REQUEST FORMNeuropathic Pain Agents Phone: 2159914300Fax back to: 8662403712Health Partners Plans manages the pharmacy drug benefit for your patient. Certain
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This is a request for specific information or action from a relevant entity or organization.
Individuals or organizations that meet certain criteria as specified by the requesting authority are required to file this request.
To fill out this request, provide the required personal or organizational information, respond to all prompts accurately, and ensure all necessary documentation is attached.
The purpose is to formally request information, services, or actions from the authority or organization to which the request is submitted.
Typically, the requester must provide details such as name, contact information, purpose of the request, and any relevant supporting documentation.
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