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Get KS KS-PAF-0673 2018

5 Urgent Request - I certify this request is urgent to treat an injury, illness or condition that could seriously jeopardize the life or health of the member, or member s ability to regain maximum function, within 24 hours. URGENT REQUESTS MUST BE SIGNED BY THE X REQUESTING PHYSICIAN TO RECEIVE PRIORITY. INDICATES REQUIRED FIELD Date of Birth * *0673* * MEMBER INFORMATION Member ID/Medicaid ID * (MMDDYYYY) Last Name, First * REQUESTING PROVIDER INFORMATION Requesting NPI * Requesting T.

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