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Get Simply Healthcare Medication Prior Authorization Form 2012-2024

â–¡ Expedited* By checking this box I certify that applying the standard 72-hour review time frame may seriously jeopardize the life or health of the patient or the patient's ability to regain maximum function. Prescriber Information Name: NPI: Phone Number: Specialty: Fax number: Medication Requested: (Please include name, strength, quantity and directions): Estimated duration of therapy: Diagnosis and pertinent clinical information: Previous medications tried for this diagnosis and when.

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