Patient authorizes the physicians, medical attendants, and the hospital to furnish full and complete medical information to the specified attorney at law, or to any representative or investigator from his/her firm. The form also provides that all prior authorization is cancelled.
Medical Authorization Form Ct In Pima
Category:
State:
Multi-State
County:
Pima
Control #:
US-00426
Format:
Word;
Rich Text
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A referral is required with this type of policy. In addition, please have your primary care doctor fax the following to the New Patient Department: .In section 2, select the "GET" information box and enter the name and address of the hospital, school, physicians, clinic, laboratory, pharmacy, insurer or. (CHNCT) to obtain access to the Medical Authorization Portal.