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Get OH OH-P-1175

66-399-0928 Phone: 800-488-0134 Paramount FAX: 419-887-2028 Phone: 800-891-2520 Unitedhealthcare Community Plan Wellcare FAX: 866-940-7328 FAX: 877-277-6892 Phone: 800-310-6826 Phone: 800-678-3184 Patient Information Patient Name DOB Molina Healthcare of Ohio FAX: 800-961-5160 Phone: 800-642-4168 Date Patient ID # Sex Pharmacy Pharmacy Phone For Injectables Only: Facility Name For Injectables Only: Facility NPI # Provider Information Prescriber Name NPI # DEA # Prescriber Special.

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