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Get AIM Preauthorization/RQI Request Fax Form

AN IMAGING MANAGEMENT PREAUTH/RQI DEPARTMENT www.americanimaging.net FAX #: 800-610-0050 FROM: Contact Person Phone #: Fax #: Subscriber (Insurance Holder) and Patient Information Patient Name: Subscriber Name: Last:___________________________ First:________________________ Last :___________________________First:_______________________________ ID #: (include alpha prefix)___________________________________ DOB:________/________/__________ SSN:____________________________________________.

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