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Get NY VillageCareMAX Request For Prior Authorization 2020-2024

Eeks prior to a request for an elective service. This form must be accompanied by all clinical information which includes medical history, results of physical exam, diagnostic tests, lab test results, functional problems, presenting symptoms and treatment plan. Incomplete requests will delay the authorization process and/or result in an adverse determination. Authorization is pending confirmation of member eligibility at time of service. If approved, authorization for service does not constitute.

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  • enrollees
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  • EMERGENT
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