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Get Complete And Fax To: (888) 6595769 Waiver Services Prior Authorization Request Clinical Information 2014-2024

On. PLEASE attach the member s service plan if requesting waiver services. Date (MMDDYY) *INDICATES Required Field Date of Birth MEMBER INFORMATION Member ID * *0773* Physician signature ONLY when required by OAC. X * (MMDDYYYY) Last Name, First REQUESTING PROVIDER INFORMATION Requesting NPI * Requesting TIN * Requesting Provider Contact Name Requesting Provider Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI * Servicing T.

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