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Get IL Medication Prior Authorization Request 2016-2024

Er above. Prior Authorizations cannot be completed over the phone Date of Request: Patient Information Prescriber Information Patient Name: Prescriber Name and Specialty: Member ID #: NPI #: Sex: Male Female Office Phone: Date of Birth: Office Fax: Patient Phone: Contact Person: Diagnosis and Medical Information Medication: Strength & Route of Administration: Frequency: Height & Weight: Expected Length of Therapy: Quantity: BMI: Date Calculated: Blood Pressure: Tak.

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