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UTAH DEPARTMENT OF HEALTH PRIOR AUTHORIZATION REQUEST FORM (sodium oxalate) Patient name: Medicaid ID #: Prescriber Name: Prescriber NPI#: Contact person: Prescriber Phone#: Extension/Option: Fax#:

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9. Who needs all information to be? Depending on the specific form or document, the recipient or the organization requesting the information typically needs all the information to be filled out accurately. This could be an employer, a landlord, a healthcare provider, a government agency, or any other entity requiring the information for documentation or decision-making purposes.
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