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Get Florida Blue Prior Authorization Form Pdf

3. Send completed Form & Pharmacy receipts to: PRIME THERAPEUTICS, LLC; P.O. Box 25136; Lehigh Valley, PA 18002-5136 I. POLICY HOLDER INFORMATION POLICY HOLDER NAME (LAST, FIRST, MIDDLE) MEMBER ID NUMBER H GROUP NUMBER DATE OF BIRTH (MM/DD/YYYY) STREET ADDRESS SEX MALE FEMALE CITY, STATE, ZIP CODE II. PATIENT INFORMATION (Must be completed if patient is a dependent child or spouse.) DATE OF BIRTH (MM/DD/YYYY) PATIENT NAME (LAST, FIRST, MIDDLE) ADDRESS.

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