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Get NY Affinity Health Plan Prior Authorization Request Form

Hone No. 877.432.6793 CareMark Fax No. 866.255.7569 Patient Information First Name: Last Name: Date of Birth: Member ID: MI: Male Is patient transitioning from a facility? / / Female Yes No If yes, provide name of facility: Provider Information First Name: NPI No: Last Name: 1 Address: Phone No: Fax No: Office Contact: Specialty: Medication/Medical and Dispensing Information Medication: Strength: Case Specif.

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