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Get United Health Care STAR+PLUS Prior Authorization Fax Request 2012-2024

Date: _____________________ Contact Person_____________________________________ Telephone #: ___________________ Fax #: _____________________Is this a HIPAA secure fax line? □ Yes □ No Requesting Provider: ________________________________ Telephone #: _________________________ Requesting Provider TIN/NPI: __________________________ Type of Request: □Routine □Urgent Urgent is defined as “significant impact to health of the member” □Expedited (Medicare Only) Request from physicia.

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