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Get Healthspring Prior Authorization

D (*) items on this form are completed** * DEA or TIN: Office Contact Person: * Patient Name: Office Phone: * CIGNA ID: Office Fax: * Date Of Birth: * Is your fax machine kept in a secure location? * May we fax our response to your office? Yes Yes Office Street Address: City No No * Patient Street Address: City State Zip State Zip Patient Phone: Medication requested: (please specify name, strength, and dosing schedule): Diagnosis related to use: Duration of therapy: Formular.

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