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Get PEHP Health & Benefits Prior Authorization For Anesthesia Services For Dental Procedures Under 2018-2024

Or benefit questions, please call PEHP Customer Service at (801) 366 7555 or toll free at (800) 753 7490. Section I: PATIENT INFORMATION Name (Last, First MI): DOB: Age: PEHP ID #: Section II: PROVIDER INFORMATION Date Requested: Service Provider NPI #: Service Provider Name: Service Provider Tax ID #: Contact Person: Service Provider Address: Phone: ( ) Facsimile: (.

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