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Get 369 Form Revised 8-25-11.indd - Medicaid Alabama

Page 1 ? Page 1 of 1 Alabama Medicaid Pharmacy Prior Authorization Request Form FAX: (800) 748-0116 Phone: (800) 748-0130 Fax or Mail to Health Information Designs ? Page 1 of 2 P.O. Box 3210 Auburn,.

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