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Get AZ Care1st Health Plan Treatment Authorization Request 2018-2024

Nt [May seriously jeopardize member’s life, health or function level] Retroactive Patient Information M ember Name: Date of Birth: M ember Address (Street): M ember Address (City, State, Zip): M ale Female M ember ID: Requesting Physician’s Name: (PLEAST PRINT) TIN/NPI: Office Contact Name: Phone: S ervice Information Referred To: TIN/NPI: Date of Request: Anticipated Date of S ervice: Fax: Specialty: Provider Address: Phone: Fax: FQHC Location?: Yes No MSIC Location? Yes.

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