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Get Smart Drx Part D Prior Authorization Form

Ll based upon AMA guidelines and elect the hospice benefit. This includes new elections, transfers from one hospice to another hospice, and transitions from home to a nursing home for those individual s that are dually eligible. This form should be completed in ink. Once the form has been signed by the physician it should not be altered. 1. PATIENT S NAME AND PHONE NUMBER: Record the recipient s name just as it is on the Medicaid card and a telephone number if applicable. 2. MEDICAID NUMBE.

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