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Get OR Health Net XO-PAF-1650 2019

For Standard requests, complete this form and FAX to 1-844-692-4065. Determination made as expeditiously as the enrollee s health condition requires, but no later than 14 calendar days after receipt of request. * INDICATES REQUIRED FIELD *1650* For Expedited requests, please CALL 1-800-672-5941. Expedited requests are made when the enrollee or his/her physician believes that waiting for a decision under the standard timeframe could place the enrollee s life, health, or ability to regain m.

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