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Riptions Rationale for Exception Request or Prior Authorization - All information must be complete and legible Patient Information First Name: Last Name: Date of Birth: Member ID: MI: Male Female Is patient transitioning from a facility? Yes If yes, provide name of facility: / / No Provider Information First Name: Last Name: NPI: Phone: Address: Fax: Office Contact: Specialty: Medication/Medical and Dispensing Inform.

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