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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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Remember, it is important to always double-check the requirements and instructions for each specific form or application you need to fill out. Pay attention to deadlines and ensure that you provide accurate and complete information to avoid any potential delays or rejections.

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All information to be can be filled out by providing accurate and complete details based on the guidelines provided.

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