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Get Pacificare Of Arizona

PRIOR-AUTHORIZATION REQUEST FORM ALL REQUESTS MUST BE FAXED PLEASE FAX THIS PAGE FIRST ON EVERY REQUEST PLEASE USE ONE REQUEST FORM PER PLACE OF SERVICE STAT / EXPEDITED NON-URGENT DATE 1 COULD SERIOUSLY JEOPARIZE THE LIFE OF HEALTH OF THE PATIENT OR 2 COULD JEOPARDIZE THE PATIENT S ABILITY TO REGAIN MAXIMUM FUNCTIONING. FOR PACIFICARE USE ONLY AUTHORIZATION MEMBER INFORMATION R E QU IR E D I N F ORM AT I ON NAME ID PROVIDER INFORMATION FAX ELIG.

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