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Get Medicaid Override Form

Ax or Mail to HEALTH INFORMATION DESIGNS P.O. Box 3210 Auburn, AL 36832-3210 PATIENT INFORMATION Patient name Patient Medicaid # Patient DOB Nursing home resident Yes Patient phone # with area code PRESCRIBER INFORMATION NPI # Prescriber name Phone # with area code License # Fax # with area code Address (Optional) Street or PO Box /City/State/Zip I certify that this treatment is indicated and necessary and meets the guidelines for use as outlined by the Alabama Medicaid Agency. I.

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