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Get CarePlus Health Services Referral Request Fax Cover Sheet 2013-2021

T - ALL EXPEDITED Requests (Must meet the following CMS definition: The provider or member believes the member’s health, life, or ability to regain maximum function is in serious jeopardy under the standard 14 calendar-day organization determination process) Clinical documentation must be submitted to support EXPEDITED classification. DO NOT USE the following terms: ASAP, Urgent, STAT—these are not CMS organizational determination terms. REQUEST DATE: _______________________ APPT. DATE: __.

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