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Get Independent Review Organization 2017-2024

Eck one: Check one:  Yes  No  Yes  No (This question does not apply if services have been received) Is this a denial of an exception request to a prescription Is the review ordered by a Court? drug step therapy protocol: Check one: Check one:  Yes  No  Yes  No DENIED SERVICES Describe the health care services that are being denied (include dates only if services have been performed): _________________________________________________________________________________________.

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