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Request for Authorization Form Request Type Long Term Care 1501 W. Fountainhead Pkwy Suite 201 Tempe AZ 85282 Telephone 866 295-9729 Fax 866 638-6126 Expedited Response required within 72 hours to avoid serious jeopardy to member s health Standard Response required within 14 days NOTE Please complete this form in its entirety. Submitting requests that are illegible incomplete missing clinical documentation and/or have an inappropriate request typ.

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