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UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION () Patient name: Medicaid ID #: Prescriber Name: Prescriber NPI#: Contact person: Prescriber Phone#: Extension/Option: Fax#: Pharmacy: Pharmacy Phone#:
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Form to 855-828-4992 is a tax form used for reporting specific information to the IRS.
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Form to 855-828-4992 requires reporting of income, deductions, credits, and other financial details as specified by the IRS.
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