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Get PA Magellan Behavioral Health Initial Referral For Family-Based Services 2022-2024

Tion must be attached. Complete all four pages and fax to 866-667-7744. Date of Referral: Referring Agency Name: Referring Agency Staff Name: Referring Agency Phone #: Referring Agency MIS #: Referring Agency Staff Email: Referring Agency Fax #: Prescribing Doctor s Name: Prescribing Doctor s Email: Prescribing Doctor s Phone #: Member Special Needs/Accommodations: (if Applicable) Member Name: Preferred Name: DOB: School Name: MA ID # (10 Digits): Gender/Pronouns: Age: Race/Et.

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