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Get Request Prior Authorization 2018-2024

Ted within 24 hours. Please Note: Urgent is defined as a health condition, including an urgent behavioral health situation, which is not an emergency but is severe or painful enough to require medical treatment evaluation or treatment within 24 hours to prevent serious deterioration of the member s condition or health. Member Information First Name Last Name Member ID* Date of Birth* Servicing Provider Information NPI* Tax ID* TPI* Contact Number* Fax Number* Last Name, First Initi.

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