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Get SCAN Prior Authorization Request Form

R days) Urgent (ASAP not to exceed 14 calendar days) Expedited/STAT (up to 3 business days) Use only when following the standard time frame could seriously jeopardize the member’s life of health or ability to attain, maintain, or regain maximum function. Member Information Member Name: Address: Phone Number: City: State: Patient ID Number: Medicare  Yes DOB:  No Zip: / / Age: Other Insurance: Requesting Physician Information Requesting Physician: Name of Person Completing.

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