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24 HOUR URGENT ATYPICAL ANTIPSYCHOTIC PRIOR AUTHORIZATION REQUEST FORM Complete ENTIRE form and Fax to: 8669407328 Today's Date SECTION PATIENT INFORMATION First Name: Last Name: Member ID: Address:

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Atypical antipsychotic - 24 is a specific type of medication used to treat certain mental health conditions such as schizophrenia and bipolar disorder.

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