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Get Standardized Prior Authorization Form Instructions - Well Sense...

Ing of request. Member Information MEMBER NAME DOB (MM/DD/YYYY) MEMBER ID# PHONE # (DIRECT LINE) FAX # Submitted by/Sender Information SUBMITTED BY Provider Information REQUESTING PROVIDER NAME NPI # PCP SPECIALIST SERVICING PROVIDER/GROUP NAME (Individuals name/group name if affiliated with multiple groups) NPI # SERVICING PROVIDER ADDRESS (At what address will member be seen?) PHONE # FAX # SERVICING FACILITY NAME NPI # Requested Services Office Visit/Consultant: CHECK REASON.

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