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Get TX Driscoll Children's Hospital Referral/Authorization Form 2000-2024

eligibility and covered benefits. ❏ CHIP ❏ STAR/Medicaid ❏ OTHER_____ HEALTH PLAN NAME: ________________________ DATE ____/____/____ Health Plan Fax# 1-866-741-5650 PATIENT INFO. Patient name ______________________________________________________________ LAST FIRST DOB ______/________/______ MIDDLE INITIAL Sex M❏ F❏ Phone # (____)____________________ Member ID #____________________ Member Social Sec. # ______-_________-________ OPTIONAL REFERRED BY Physician name ____________.

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