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Get Ri Nhp Non Emergency Ambulance Transportation Prior Authorization Form 2013-2024

Al Medical Policy which is available on our Neighborhood web site, www.nhpri.org for more detailed information about this benefit, authorization requirements, and coverage criteria. Member s Name: MEMBER INFORMATION Member s ID #: Member s DOB: Provider s Name: PROVIDER INFORMATION Supplier ID or NPI #: Date of Request: Date of Service: Previous Auth #: Place of Service (City/Town)/Facility: Provider s Phone #: Provider s Fax #: Provider s Contact Name: CLINICAL INFORM.

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