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Get TX Referral/Authorization Form - Parkland

Te for outpatient facility, List CPT4 at right Facility # * _____________________________* † † † † Provider City ____________________________, Texas † ER/Post Stabilization † Other ROUTINE † URGENT EMERGENCY OUT OF NETWORK REVISED REFERRAL NOTIFICATION ONLY **Refer to specific plan instructions. Certification/authorization guidelines must be followed. Fax # (______)____________________ LAST † † † † † † Lab/Pathology † Radiology/ Imaging † Therapy: Indicate # of visits _.

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