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Get Tx F00120 2016-2024

Zed by the Provider (hereinafter "Prior Authorization Request Submitter") to submit this prior authorization request. The Provider and Prior Authorization Request Submitter certify and affirm under penalty of perjury that they are personally acquainted with the information supplied on the prior authorization form and any attachments or accompanying information and that it constitutes true, correct, complete and accurate information; does not contain any misrepresentations; and does not fail to i.

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