Get the free Suboxone Prior Authorization Criteria - Optum New Mexico
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NewMexicoMedicaidPriorAuthorizationFormfor
Suboxone(buprenorphine/naloxone)orSubutex(buprenorphine)
(Approvaldoesnotensureeligibility.Pleaseverifyeligibilitybeforecompletingthisform.)
PatientName:
InsuranceID/SS#:
DOB:
Insurance(pleasecircle):BlueSaludLovelaceSaludMolinaSaludOptumHealthNMPresbyterianSalud
MD/DOName:
MD/DOPhone:
MD/DOSignature:
Fax#:
OfficeContactName:
SubmittedDate:
OfficeContactPh
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