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Get Ky Unbridled Spirit Medicaid

Date of Request Prior Authorization Fax Form Complete this Form and Fax to 1-855-252-0567 NON-PAR SERVICES REQUIRE AUTHORIZATION PRIOR TO SERVICE BEING RENDERED Emergency and Post-Stabilization Care Does NOT Require Prior Authorization Emergent/urgent inpatient admissions and observation hospital stays require Plan notification within 1 business day of the Admission Ordering Physician Name Ordering Provider Contact Ordering Provider Phone Orderin.

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