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Please complete the following and sign below. The form must be legible, and all fields should be filled out as completely as.NOTE: Complete this form if you are requesting DMV to release your driving record to anyone other than yourself. Charleston, WV 25304. Phone (800) 841-6212 OR (304) 558-7815. "Prior Authorization" means obtaining advance approval from a health maintenance organization about the coverage of a service or medication. Start, continue, or complete an application; Amend a pending application; Print Authorization and Release forms. The purpose of the project is to obtain an automated prior authorization system that will allow pharmacists to submit claims through the. Application, West Virginia Online Addendum and the WVBOM Photo Affidavit and Authorization for. 1 Medical Park Wheeling, WV 26003.