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UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM () Patient name: Medicaid ID #: Prescriber Name: Prescriber NPI#: Contact person: Prescriber Phone#: Extension/Option: Fax#: Pharmacy: Pharmacy
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What is pharmacypharmacy phonepharmacy fax?
Pharmacy's phone number and fax number are contact information for the pharmacy.
Who is required to file pharmacypharmacy phonepharmacy fax?
The pharmacy staff or designated individuals are required to file the pharmacy's phone number and fax number.
How to fill out pharmacypharmacy phonepharmacy fax?
To fill out the pharmacy's phone number and fax number, provide the accurate contact information for the pharmacy.
What is the purpose of pharmacypharmacy phonepharmacy fax?
The purpose of providing the pharmacy's phone number and fax number is to have a reliable contact method for communication.
What information must be reported on pharmacypharmacy phonepharmacy fax?
The required information for the pharmacy's phone number and fax number includes the accurate contact details.
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