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Get CA Precription Drug Prior Authorization Request Form - Los Angeles 2016-2024

X Attachments PLEASE ATTACH RELEVANT PROGRESS NOTE, LABS, CURRENT MEDS, and CLINICAL RATIONALE Attestation: I attest the information provided is true and accurate to the best of my knowledge. I understand that the Health Plan, insurer, Medical Group or its designees may perform a routine audit and request the medical information necessary to verify the accuracy of the information reported on this form. Prescriber Signature: Date: Confidentiality Notice: The documents accompanying this tra.

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