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REQUEST FOR SERVICE AUTHORIZATION FOR OUT-OF-STATE SERVICES Clear Fields NORTH DAKOTA DEPARTMENT OF HUMAN SERVICES MEDICAL SERVICES DIVISION Medically Urgent SFN 769 Rev. 8-2014 SEND TO ND DEPARTMENT OF HUMAN SERVICES 600 E BOULEVARD AVE DEPT 325 BISMARCK ND 58505-0250 FAX 701 328-0376 TO BE COMPLETED BY A NORTH DAKOTA REFERRING PHYSICIAN ONLY NOTE AN INCOMPLETE FORM WILL DELAY THE AUTHORIZATION PROCESS. Approval of this request is not authorizat.

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