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Est is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 48 hours to avoid complications and unnecessary suffering or severe pain. Urgent requests must be signed by the requesting physician to receive priority. X * INDICATES Required Field Date of Birth MEMBER INFORMATION Member ID/Medicaid ID * Requesting NPI * Requesting TIN * Requesting Provider Contact Name Requesting Provider Name Phone SERVICING PROVIDER / FACILITY INFORMATI.

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