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Get PA MA 97 2005-2024

Or authorization - or - 1150 Waiver are on the reverse of this sheet for your convenience as they relate to each section of the form. When the form is completed, remove this sheet at the perforation. Then, remove the first copy of the MA 97 and send it to the appropriate address as indicated below. For those services which require a prescription, attach a copy of the Rx to the MA 97. Retain the second copy for your record. FOR SHIFT NURSING OUTPATIENT SERVICES, SEND TO: OUTPATIENT PA / 1150 WAIV.

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