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REQUEST FOR PRIOR AUTHORIZATION FAX TO: 8772716290 CONTINUATION OF SERVICES YES P.A. NUMBER: NO (1) PRIOR AUTHORIZATION TYPE: (2) MEMBER ID NUMBER EPS DT PCS (3) SOCIAL SECURITY # (4) MEMBER LAST
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Revised pa-14 05 05 is a form used for reporting certain financial information.
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Individuals or entities with specific financial transactions are required to file revised pa-14 05 05.
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