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85711 For copies of prior authorization forms and guidelines please call 800 410-6565 or visit the provider portal at www. Prior Authorization / Formulary Exception Request Fax Form FAX TO 800 977-4170 Form must be fully completed to avoid a processing delay. For status of a request call 800 410-6565 Patient s Name Last First MI Date of Birth ------------------- MM / DD / YYYY ------------------- / Member ID ------------ Please print clearly and .

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