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Get LA Healthcare Connections LA-PAF-0658 2016-2024

0658* Standard Request - Determination within 14 calendar days of receipt of the request. Urgent Request - I certify this request is urgent and medically necessary to treat an injury, illness or condition (not life threatening) within 72 hours to avoid complications and unnecessary suffering or severe pain. URGENT REQUESTS MUST BE SIGNED BY THE X REQUESTING PHYSICIAN TO RECEIVE PRIORITY. INDICATES REQUIRED FIELD Date of Birth * * MEMBER INFORMATION Member ID/Medicaid ID * (MMDDYYYY) Last Na.

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