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Get Moda Health Prior Authorization PA Request Form

D#: HQ Code: PHYSICIAN INFORMATION Name: Phone: Fax: Contact Name: MEDICATION INFORMATION Medication Name: Strength: Frequency: ICD-9 Code: Medications previously tried by the member Medication name and strength Dates used (approximate) Documentation of failure Circumstances for Medical Necessity: ***PLEASE RESPOND TO ALL QUESTIONS ON THE FOLLOWING PAGE(S)*** INTERNAL USE ONLY Date received: Date of review: Reason for Clinical Review: PAC: Does not meet criteria DAW Difference .

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