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Get WA Molina Healthcare Behavioral Health Authorization/Notification Form 2019-2024

Ketplace Request Type: Initial Date of Request: Concurrent Admit/Start Date of Services: Honor Authorization (Medicaid suspended due to incarceration) Member Name: DOB: Member ID#: Member Phone: Service is: Elective/Routine Expedited/Urgent* *A service request designation is defined as Expedited/Urgent when the treatment requested is required to prevent serious deterioration of the member s health, or if not received could jeopardize the member s ability to r.

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