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Get Louisiana Medicaid Pcp Referral Form

CAL ASSISTANCE PROGRAM REQUEST FOR PRIOR AUTHORIZATION PRIOR AUTHORIZATION TYPE 07- AIR AMBULANCE 7-DIGIT MEDICAID PROVIDER NUMBER / / / / / (3) (1 ) (2) DATE OF BIRTH RECIPIENT 13-THIRTEEN DIGIT MEDICAID NUMBER OR 16-SIXTEEN DIGIT CCN NUMBER / / / / / / RECIPIENT LAST NAME / / (4) / / / / / / (5) FIRST / / / DATES OF SERVICE FROM THRU / (6) DIAGNOSIS PRIMARY CODE AND DESCRIPTION STATUS CODES: 2 APPROVED 3 DENY P.A REVIEWER SIGNATURE: & DATE DESCRIPTION.

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