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Get Anthem Therapy Fax Request Form

ANTHEM Therapy Fax Request Form PLEASE USE THIS FORM FOR ALL NH CT ANTHEM MEMBERS 43733 Fax Date of Pages Faxed Please fax to OrthoNet at 1-888-788-0809 THERAPY PROVIDER INFORMATION Facility or Provider Name Street Address City State Telephone Number ZIP FAX Number - The above fax number will be used to confirm your address/location if we are unable to contact you using the fax number on file with Anthem. National Provider Identifier NPI Individu.

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