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Get Medicare Part D Coverage Determination Request Form. Medicare Part D Coverage Determination Request

Request for Expedited Review REQUEST FOR EXPEDITED REVIEW 24 HOURS BY CHECKING THIS BOX AND SIGNING ABOVE, I CERTIFY THAT APPLYING THE 72 HOUR STANDARD REVIEW TIME FRAME MAY SERIOUSLY JEOPARDIZE THE LIFE OR HEALTH OF THE MEMBER OR THE MEMBER S ABILITY TO REGAIN MAXIMUM FUNCTION Information on this form is protected Health Information.

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