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PRIOR AUTHORIZATION REQUEST FORM Fax to (812) 2547426 Please note the request MUST include: 1. Office notes Electronic office notes correlating to the diagnosis or Handwritten office notes including
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Clearly outline the modifications that have been made, including the reason for the changes.
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The Summary of Material Modifications is a document that outlines any changes made to a employee benefit plan.
Employers or plan administrators are required to file the Summary of Material Modifications.
The Summary of Material Modifications is usually filled out by providing details of the modifications made to the employee benefit plan.
The purpose of the Summary of Material Modifications is to inform participants of any important changes made to their benefit plan.
The Summary of Material Modifications must include details of the changes made to the plan, such as amendments or changes to benefits.
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