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Get MI WF 12173 2011

X RECERTIFICATION PRECERTIFICATION Complete this form and fax it to: 1-866-464-8223 Or E-FAX/E-Mail to MedicarePlusBlueFacilityFax@bcbsm.com Include hospital admission H&P and PM&R consultation notes (as applicable) Facility and provider must participate with local BCBS plan or member may incur sanctions. Complete every field unless otherwise noted. Information must be legible. Place N/A if not applicable. INCOMPLETE SUBMISSIONS WILL BE RETURNED UNPROCESSED. MA PPO DISCLAIMER STATEMENTS AND.

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