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Get Bmc Prior Authorization

The pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. Patient Name: Prescriber Name: Member/Subscriber Number: Fax: Date of Birth: Office Contact: Group Number: NPI: Address: Address: City, State ZIP: City, State ZIP: Primary Phone: Specialty/facility.

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