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CIGNA HealthCare Prior Authorization Form - Pharmacy Services Notice Failure to complete this form in its entirety or include chart notes may result in delayed processing or an adverse determination for insufficient information. Phone 800 244-6224 Fax 800 390-9745 PROVIDER INFORMATION PATIENT INFORMATION Provider Name Specialty Due to privacy regulations we will not be able to respond via fax with the outcome of our review unles.

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