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Get Cigna Healthcare Prior Authorization Form 2010-2024

Erse determination for insufficient information. Phone: (800)244-6224 Fax: (800)390-9745 PROVIDER INFORMATION PATIENT INFORMATION * Provider Name: Specialty: **Due to privacy regulations we will not be able to respond via fax with the outcome of our review unless all asterisked (*) items on this form are completed** * DEA or TIN: Office Contact Person: * Patient Name: Office Phone: * CIGNA ID: Office Fax: * Date Of Birth: * Is your fax machine kept in a secure location? * May we fax.

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