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WELLCARE INJECTABLE INFUSION FORM Prior Authorization Request for WellCare of Florida Staywell and HealthEase FAX to 1-866-825-2884 WellCare Pharmacy - Injectable Infusion Department Requested by Physician Member Pharmacy Appointed Representative Complete each section legibly and completely include any additional Date necessary medical records or laboratory results Submitted Member ID Provider ID Name Address City State Zip Phone DOB Contact .

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