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Get Priority Partners Pharmacy Prior Authorization Form 2014-2024

Cy Prior Authorization Form FAX Completed Form AND APPLICABLE PROGRESS NOTES to: (410) 424-4607 Or (410)424-4751 Download a copy of this form on our website at: www.ppmco.org Member Info (Please Print Legibly) NAME: MEDICAID #: DOB: SEX: PPMCO #: Provider Info NAME: Office Telephone: Office Contact Name: Office FAX: Medication Requested Drug Name Strength Dosage/Frequency (SIG) Diagnosis / Clinical Rationale / Pertinent Labs **Attach Previous Formulary Trial(s) Duration of T.

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