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Your Health, Our Commitment

2020 Ponce de Leon Blvd, Suite PH 1, Coral Gables, FL 33134

Prior Authorization Form

 

CMS defines expedited as those requests where applying the standard timeframe could seriously jeopardize the life or health of the enrollee or the enrollee’s ability to regain maximum function.

Patient Information

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Requesting Provider Information

Street Name and Number

Primary Care Physician Information

Referral Information

Street Name and Number

Diagnosis

(Please enter all diagnosis for member and separate each with a comma, for example; Z00.00, Z13.1)

Services Requested

(Please enter the codes for all services requested and separate each with a comma, for example; 93306, 72148)

Please upload Prescription/Order and all supporting clinical documentation

Click or drag files to this area to upload. You can upload up to 3 files.
The file formats you can upload are .tiff, .jpg, .png, .doc, and .pdf. If attachment is over 10MB, please split the file to conform to size limit.
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Last Updated: 10/30/2020

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