endobj 290 0 obj endobj The best way to edit Optumrx tier exception form in PDF format online 9.5 Ease of Setup DocHub User Ratings on G2 9.0 Ease of Use DocHub User Ratings on G2 Handling paperwork with our comprehensive and intuitive PDF editor is straightforward. Fax Number: 1-844-403-1028 Prior Authorization Department . PA reviews are completed by clinical pharmacists and/or medical doctors who base utilization Download now. For forms to request prior authorization for drugs covered under the retail pharmacy benefit, please visit the OptumRx Healthcare Professionals Portal. endobj Once a review is complete, the provider is informed whether the PA request has been approved or coverage determinations for most PA types and reasons. Any device can be used, such as a phone, tablet, or laptop. Optimal. Supply the diagnosis followed by a list of medications that have been tried and failed and the date on which each drug was prescribed. 14 0 obj 141 0 obj Show details How it works Open the covermymeds prior authorization form pdf and follow the instructions Easily sign the covermymeds optumrx with your finger endstream endobj 343 0 obj <>/Metadata 15 0 R/Names 372 0 R/Pages 339 0 R/StructTreeRoot 33 0 R/Type/Catalog/ViewerPreferences 373 0 R>> endobj 344 0 obj <>/MediaBox[0 0 612 792]/Parent 339 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> endobj 345 0 obj <>stream ee` fd Enter your official identification and contact details. [19 0 R 21 0 R 22 0 R 24 0 R 186 0 R 187 0 R 187 0 R 187 0 R 187 0 R 187 0 R 184 0 R 185 0 R 185 0 R 185 0 R 185 0 R 185 0 R 183 0 R 180 0 R 179 0 R 178 0 R 175 0 R 174 0 R 173 0 R 172 0 R 168 0 R 167 0 R 166 0 R 163 0 R 162 0 R 161 0 R 158 0 R 157 0 R 156 0 R 155 0 R 154 0 R 149 0 R 148 0 R 147 0 R 146 0 R 145 0 R 139 0 R 140 0 R 140 0 R 140 0 R 140 0 R 140 0 R 138 0 R 135 0 R 136 0 R 134 0 R 133 0 R 132 0 R 128 0 R 127 0 R 126 0 R 123 0 R 122 0 R 119 0 R 118 0 R 114 0 R 115 0 R 115 0 R 115 0 R 115 0 R 115 0 R 113 0 R 100 0 R 101 0 R 102 0 R 103 0 R 104 0 R 105 0 R 106 0 R 107 0 R 108 0 R 109 0 R 110 0 R 111 0 R 99 0 R 56 0 R 57 0 R 58 0 R 97 0 R 96 0 R 93 0 R 92 0 R 89 0 R 88 0 R 85 0 R 84 0 R 81 0 R 78 0 R 79 0 R 80 0 R 75 0 R 74 0 R 71 0 R 70 0 R 60 0 R 55 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 20 0 R 25 0 R 188 0 R 191 0 R 189 0 R 27 0 R 28 0 R 23 0 R] Take advantage of the top and left-side panel tools to redact Optumrx prior authorization form pdf 2021. Use the Sign Tool to add and create your electronic signature to signNow the Optimal prior authorization form. Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. 1.1 endstream 195 0 obj If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. If you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against . Microsoft Word 2010 O4 Footer. You need to record the rights and responsibilities of the sides within the field. Follow the instructions below to fill out Optumrx tier exception form online quickly and easily: But there are circumstances where there's misalignment between what is approved by the payer and what is actually . A list of tried and failed medication must be provided as a justification for the request alongside the diagnosis. Make adjustments to the template. <>/MediaBox[0 0 612 792]/Parent 192 0 R/Resources<>/Font<>/ProcSet[/PDF/Text]/XObject<>>>/Rotate 0/StructParents 0/Tabs/W/Type/Page>> Please note: All information below is required to process this request 192 0 obj Over 2/3 of the PAs that we receive each year are now electronic. Click the New Document option above, then drag and . To ensure that a PA determination is provided to you in a timely That's why we have a team of experts and a variety of help resources to make requests faster and easier. Prior authorization (PA) requires your doctor to tell us why you are taking a medication to determine . Sign in to the editor with your credentials or click Create free account to evaluate the tool's features. Santa Ana, CA 92799 . 374 0 obj Make these fast steps to modify the PDF Optumrx prior authorization form online free of charge: Sign up and log in to your account. Box 25183 . Prior authorization Select. endobj %PDF-1.7 % These rights are collectively known as Individual Rights. Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. <>stream This will require the following: Step 4 The medications name, strength and dosage form must be enter next. <> Un Representante Personal puede ser legalmente designado o nombrado por el miembro o el paciente para actuar en su nombre. For requests for buy and bill, please contact the patients medical benefit. 2 - Express Scripts data on file, 2019. endobj endobj OptumRx has partnered with CoverMyMeds to receive prior authorization requests, . Optum Prior Authorization Criteria Specific Forms. For Personal Representatives that have been legally appointed, the Personal Representative can complete this form and attach supporting legal documentation, such as a Power of Attorney that indicates full health care decision-making authority, guardianship documentation, etc. Microsoft Word 2010 the OptumRx UM Program. %%EOF <> Select the area you want to sign and click. <>stream endobj Follow the Support section or get in touch with our Support team in the event that you have got any concerns. types (step therapy, PA, initial or reauthorization) and approval criteria, duration, effective Click here to view the OptumRx PA guidelines and Exception Request Procedures. If you cannot submit requests to the OptumRx PA department through ePA or telephone,click here. Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) 140 0 obj TheOptumRX Prior Authorization Request Formis a simple form to be filled out by the prescriber that requests that a certain treatment or medication be covered for a patient. Specialty drugs and prior authorizations. Add the Optumrx prior authorization form for redacting. HWn8}WiIJAdu$,d(j[~V&nge^U9UV ^<. allowed by state or federal law. <> covered medication, and/or OptumRx will offer information on the process to appeal the adverse decision. Start a Prior Authorization with CoverMyMeds > No hold times. 752dc44aac14d1f9c79b428b5625173e746a1557 The following January 1, 2023 flyers are sent to members to outline the drugs affected by prior authorization, quantity limits, and step therapy based on benefit plan designs. 1 0 obj Decide on what kind of signature to create. 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There are three variants; a typed, drawn or uploaded signature. review decisions on sound clinical evidence and make a determination within the timeframe A Personal Representative may be legally appointed or designated by the member or patient to act on their behalf. Dermatology. En el caso de los Representantes Personales que hayan sido legalmente designados, pueden llenar este formulario y adjuntar documentacin legal de respaldo, tales como un Poder que indique la autoridad total para tomar decisiones sobre la atencin de la salud, documentacin de la tutela, etc. Utilization management updates . endobj See buprenorphine/naloxone tab prior authorization criteria Additionally, a documented allergy to inactive ingredient in preferred product that is not in requested product 12/3mg: 1/day 8/2mg: 2/day 4/1mg: 2/day 2/0.5mg: 3/day ^ Zubsolv NP . OptumRx Prior Authorization Guidelines and Procedures Enter their name, insurance ID number, DOB, full address, and phone number. making criteria** that are developed from clinical evidence from the following sources: *Guidelines are specific to plans utilizing our standard drug lists only. Find the extension in the Web Store and push, Click on the link to the document you want to design and select. IME: Prior Authorization Form Tips. Call 1-800-711-4555, 5 a.m. 10 p.m. PT, Monday-Friday and 6 a.m. 3 p.m. PT, Saturday. 370 0 obj <>/Filter/FlateDecode/ID[<6A51065327B04A46813B4732261321B1>]/Index[342 73]/Info 341 0 R/Length 135/Prev 314608/Root 343 0 R/Size 415/Type/XRef/W[1 3 1]>>stream OptumRX Prior Prescription Authorization Form Step 2 - The first required information is that of the member. Author: Miley, David T Created Date: 12/23/2022 9:56:07 AM . Select the area where you want to insert your signature and then draw it in the popup window. Open PDF, opens in a new tab or window. 139 0 obj Verify your NPI to receive all requests initiated at your patients pharmacies, Use your account to initiate, access and submit requests, HIPAA compliant and available for all plans and all medications. 0 Call 1-800-711-4555, 5 a.m. 10 p.m. PT, Monday-Friday and 6 a.m. 3 p.m. PT, Saturday. dates and more. Select the document you want to sign and click. 2016-09-16T07:22:50.000-05:00 If the patient is not able to meet the above standard prior authorization requirements, please call 1-800 -711 -4555. Step 6 Check the yes box to indicate that all the information provided is both true and accurate. 2 0 obj After that, your optimal prior authorization form is ready. This request does not allow your designated person to make any of your treatment decisions or direct care decisions. For urgent or expedited requests please call 1-800-711-4555. hVn8>X$I"(8qhEnDX2$I~P-;v4pf4s52tL0 BLI`VL Y3(9d6sa$@9t!Xu! DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. Step 3 Next, to the right of the member info, supply the healthcare provider info. Use este formulario para identificar una persona que pueda tomar las decisiones sobre su atencin de la salud, solicitar y divulgar su informacin de salud protegida, o ejercer sus derechos en su nombre. 414 0 obj <>stream signNow makes signing easier and more convenient since it provides users with a range of additional features like Invite to Sign, Add Fields, Merge Documents, and many others. Microsoft Word 2010 OptumRx Prior Authorization Guidelines and Procedures Install the signNow application on your iOS device. ePA can save time for you and your staff, leaving more time to focus on patient care. prescription drug benefit coverage under his/her health insurance plan or call OptumRx. telephone or fax. Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. Open PDF, opens in a new tab or window. Click on New Document and select the form importing option: upload Optumrx prior authorization form pdf 2021 from your device, the cloud, or a protected link. Step 5 The clinical information window is required. 15 0 obj LET's GET STARTED. O4 2 Columns (1/2 - 1/2) O4 Text Component. For medications not listed on this form, please refer to our partners at . Our electronic prior authorization (ePA) solution provides a safety net to ensure the right information needed for a determination gets to patients' health plans as fast as possible. If you have questions, please call 800-310-6826. The OptumRx Pharmacy Utilization Management (UM) Program utilizes drug-specific prior Prior authorization form. Prior Authorization Form Mavyret This document and others if attached contain information that is privileged, confidential and/or may contain protected health information (PHI). Injectable Psychotropic - Optum. Improving efficiencies without sacrificing the essentials, Three Easy steps to completing requests electronically. Super Fast Download Medicaid Prior Authorization video HD Youtube HD. As part of an ongoing effort to increase security, accuracy, and timeliness of PA Refer to the Support section or contact our Support crew in the event that you have any concerns. submitting pharmacy prior authorization requests for all plans managed by 2023 CoverMyMeds LLC. prescription drug benefits may be covered under his/her plan-specific formulary for which Get access to thousands of forms. Formulario de Representantes Personales (Espaol). Who May Make a Request: We know PA requests are complex. Patients. Optumrx Prior Authorization Appeal Form 2019-2023 Use a go covermymeds optumrx 2019 template to make your document workflow more streamlined. endobj Loginto your preferred web-based portal account and select New Requestwithin hbbd```b``:"@$"&&@${ "Y`. Enter in the date and, once the document has been printed off, sign the signature field. ", Arkansas Prior Authorization or Exception Request, Online Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others, Claim Form Medicare Part D Frequently Asked Questions English, Claim Form Medicare Part D Frequently Asked Questions Spanish, Claim Form: UHG, Medicare, PDP, MAPD, Commercial, PPO, Union and Others. therapy and non-formulary exception requests. OptumRx New Prescription Physician Fax Download - Medicaid Prior Authorization video, BNK.WIKI. [292 0 R 293 0 R 294 0 R 295 0 R 296 0 R 297 0 R 298 0 R 299 0 R 300 0 R 301 0 R 302 0 R 303 0 R 304 0 R 305 0 R 306 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 314 0 R 315 0 R 316 0 R 313 0 R 373 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R 325 0 R 326 0 R 327 0 R 328 0 R 329 0 R 330 0 R 331 0 R 332 0 R 333 0 R 334 0 R 335 0 R 336 0 R 337 0 R] OptumRx, except for the following states: MA, RI, SC, and TX. 8X R@, f`\iW sXXNe`pj! Arizona: Commercial Prescription Prior Authorization Form for Prescription Drug, DME-Medical Devices . 2016-12-02T11:43:26.719-06:00 As an OptumRx provider, you know that certain medications require approval, or Provider named above is required to safeguard PHI by applicable law. This info will allow those at OptumRX to determine whether or not partial or full coverage is feasible. uuid:57a4631a-2f5b-460a-a79e-d6d5b547b995 This form may contain multiple pages. 17 0 obj Submit a prior authorization; Utilization management changes, effective 01/01/23; DPL Main Nav Items . endstream FORMS ARE UPDATED FREQUENTLY AND MAY BE BARCODED . endobj Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE. The PDF form you wish to fill out will contain the next areas: Jot down the data in ICD, Codes. We know PA requests are complex. 398 0 obj 17 January, 2018 Introduction to OptumRx. If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. We offer other various resources to help support your understanding and use of ePA. %%EOF 16 0 obj Electronic payment solutions; FAQs; Fraud, waste, abuse and general compliance; Forms; Formulary and updates; Guides, manuals and training; Notices; Payer sheets; See all; DPL Main Nav Items. Use this form in Arizona, Nevada and Utah. 385 0 obj $&`vi RHw2e`. <>/MediaBox[0 0 612 792]/Parent 136 0 R/Resources<>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/Type/Page>> requests and determinations, OptumRx is retiring most fax numbers used for Viewand print a PA request form, For urgent requests, please call us at 1-800-711-4555. <> If you are new to electronic prior authorizations (ePA), here are a few benefits to consider: Saves time: Providers who report using ePA submissions on average spend 2.5 fewer hours on PAs per week*, Provides real-time submissions with typical resolutions in less than 5 minutes at no additional cost, Eliminates wait time on the phone or using manual fax forms, Reduces disruptions to patient care, Allows renewals to be created from previous submissions, Includes specific clinical questions pertinent to patient plan requirements, Reduces paperwork: Process is eco-friendly, Protects patient health information: Provides secure transmission using the National Council for Prescription Drug Programs (NCPDP) SCRIPT standard, Save time today and submit your PA requests to OptumRx through any of the following online portals:**. The advanced tools of the editor will lead you through the editable PDF template. PAs help manage costs, control misuse, and these guidelines may not apply. We recommend you speak with your patient regarding The Provider named above is required to safeguard PHI by applicable law. Please note: All information below is required to process this request . Enter their name, insurance ID number, DOB, full address, and phone number. Providers. V3`#lK2m%\ekvNYN9(^,4b"wx?_y=X]>d''x7|{rO0slTZcL(A$9cOij&KM?|PW( ~?: ,5/V!}=#Y:w53~))$VS|4Bq")rUj7nN'7C|v C*rMFDMdb)y]E*DJc 05ZAk YyY_4NdEsAk^OI"@D_ 02 Double check all the fillable fields to ensure complete accuracy. Step 2 The first required information is that of the member. Submitting a PA request Did you know Over 2/3 of the PAs that we receive each year are now electronic. Get Form Now Download PDF Optumrx Prior Authorization Form PDF Details It enables a faster turnaround time of coverage determinations for most PA types and reasons. Formulario de autorizacin - PDF en espaol. endobj 13 0 obj Find OptumRx formularies, formulary updates . Use the Sign Tool to add and create your electronic signature to signNow the Prior Authorization Request Form Member . ** OptumRxs Senior Medical Director provides ongoing evaluation and quality assessment of Send filled & signed optiumrx or save. That's why we have a team of experts and a variety of help resources to make requests faster and easier. I have been using this service since last year and it simply gets better and better. Personal Representative form - English PDF. Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. Please contact the OptumRx Prior Authorization department at 1-800-711-4555 or . Other ways to submit a prior authorization, Having difficulties with ePA? Now you'll be able to print, download, or share the document. Authorization form - English PDF Formulario Estndar de Autorizacin para la Divulgacin de Informacin de Salud Protegida (PHI) (Espaol) Usamos este formulario para obtener su consentimiento por escrito para divulgar su informacin de salud protegida (protected health information, PHI) a alguien que usted haya designado. O4 Footer Nav Items. . All you have to do is download it or send it via email. uuid:94c837f8-2907-48ac-b6be-ad7166d0dcfe Create your signature, and apply it to the page. that will help the reviewing process. Step 3: Click the Done button to save the file. Top. It has significantly reduced the paperwork burden of my office and office staff as far as prior authorizations go. See the ePA Video Overview below to learn more. reason prescribed before they can be covered. Open PDF, opens in a new tab or window. We work with. <> Please complete all pages to avoid a delay in our decision. ePA is a secure and easy method for submitting,managing, tracking PAs, step Draw your signature or initials, place it in the corresponding field and save the changes. This form must be completed in full and double checked for accuracy before being faxed to the insurance company for review. Create an account using your email or sign in via Google or Facebook. OptumRx is not authorized to review requests for medications supplied by the physicians office. Proper consent to disclose PHI between these parties has been obtained. prior authorization (PA), to ensure that they are medically necessary and appropriate for the Lack of information may delay <> Your patients Go to the Chrome Web Store and add the signNow extension to your browser. Member Information Prescriber Information Member Name: Provider Name . endobj <> This form may be used for non-urgent requests and faxed to 1-844 -403 -1028 . Formulario de designacin de representante personal - PDF en espaol, Stay up to date on the latest OptumRx information, Medicaid customers, please use the appropriate state form below, The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy Rule gives you rights over your protected health information (PHI), including the right to get it, change it, share it and monitor it. **The ePA solution supports all forms of PA and formulary exception requests. This form may be used for non-urgent requests and faxed to 1-800-527-0531. 1 Use este formulario para dar su consentimiento para la divulgacin de la informacin de salud protegida tanto verbal como escrita, que incluye su perfil o registro de recetas, a la persona que usted haya designado en el formulario. Created Date: 10/19/2020 8:48:26 AM . Easily sign the optumrx prior authorization form 2022 with your finger. `HJsCiG:!HY5VX1rAZvdZ Our site is the place to go if you want to edit and acquire this form. startxref 3 0 obj Exclusions may include cost reduction requests such as tiering exception, copay waiver, and tier cost sharing.To submit a tiering exception, copay waiver, tier cost sharing, or any other cost reductions requests (e.g., HCR), please contact the OptumRx PA department through Click thislinkto leverage theAMA's video seriesto educate your staff about the advantages of ePA. Click here to view the OptumRx PA guidelines and Exception Request Procedures. You may also ask us for a coverage determination by calling the member services number on the back of your ID card. 158 0 obj endobj Open the doc and select the page that needs to be signed. If the physician is supply the medication, check that this is the case. Injectable Psychotropic - Optum. optumrx appeal form pdf. encourage providers to submit PA requests using the ePA process as described Crohn's/Ulcerative Colitis. Please review each document for more details. Open PDF, . If denied, the provider may choose to prescribe a less costly but equally effective, alternative your Dashboard to submit your PA request. <>/Filter/FlateDecode/ID[]/Index[138 56]/Info 137 0 R/Length 102/Prev 122747/Root 139 0 R/Size 194/Type/XRef/W[1 3 1]>>stream Add the PDF you want to work with using your camera or cloud storage by clicking on the. July 1, 2022. Prior Prescription (RX) Authorization Forms, OptumRX Prior Prescription (Rx) Authorization Form, CVS Prior Prescription (Rx) Authorization Form, CIGNA Prior Prescription (Rx) Authorization Form, Future Scripts Prior Prescription (Rx) Authorization Form, Meridian Prior Prescription (Rx) Authorization Form, Amerigroup Prior Prescription (Rx) Authorization Form, EnvisionRX Prior Prescription (Rx) Authorization Form, Humana Prior Prescription (Rx) Authorization Form, Harvard Pilgrim Healthcare Prior Prescription (Rx) Authorization Form, Authorization Forms Adobe PDF and Microsoft Word. You can submit a verbal PA request. endobj If yes, answer the two accompanying questions. 216205 Esta solicitud no permite que esta persona tome decisiones sobre su tratamiento ni decisiones directas sobre la atencin de la salud. If providers are unable to submit electronically, we offer the following options: Call 1-800-711-4555 to submit a verbal PA request Press Done after you finish the blank. stream Guidelines are based on written objective pharmaceutical UM decision- OptumRx Prior Authorization Health care professionals website Prior authorization for prescribers Prior authorizations (PAs) help manage costs, control misuse and protect patient safety to ensure the best possible therapeutic outcomes. Miley, David T In the Prior, Authorization, Request, Form, Page, of bedtime, and Please, note area, highlight the important data. % x=i ?$u-)7^,fh${/dW{=N8h.b^=>^m>xsw}O'?iG_B4eUoZ=*l___. O4 1 Column (Full) O4 Text Component. We offer other various resources to help support your understanding and use of ePA. 4 0 obj Submitting prior authorizations via ePA (electronic prior authorization) is the fastest and most convenient method for submitting prior authorizations. 138 0 obj This form may be used for non-urgent requests and faxed to 1-800-527-0531. For requests for buy and bill, please contact the patients medical benefit. The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. Open PDF, opens in a new tab or window. See buprenorphine/naloxone tab prior authorization criteria endobj they may: Allow at least 24 hours for review. For urgent or expedited requests please call 1-800 -711 -4555. It enables a faster turnaround time of DPL-Footer Legal And Social Bar Component, Utilization management changes, effective 01/01/23, Fraud, waste, abuse and general compliance, Language Assistance / Non-Discrimination Notice, Asistencia de Idiomas / Aviso de no Discriminacin. <>stream the decision-making process and may result in a denial unless all required information is received. We strongly <>stream hbbd```b``[A$;fGH."Y@${8 "Y&(H RKD2DH`vdowmybefbC>10120>8B ) Fax the form, once 100% complete, to1 (800) 711-4555 if this is an expedited request, or to1 (800) 527-0531 if the need for the medication could be classified as non-urgent. Press Done after you fill out the blank. <>>> O4 Footer Nav. 342 0 obj <> endobj manner, please submit all information needed to make a decision. The American Medical Association (AMA) wants to help bring ePA awareness to physician practices. <>/ExtGState<>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/Annots[ 15 0 R 16 0 R 17 0 R 20 0 R 21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R 41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R 51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R 71 0 R 72 0 R] /MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> If the patient is not able to meet the above standard prior authorization requirements, please call 1-800-711-4555. . To exercise your rights under HIPAA, click here. 2016-09-16T07:22:50.000-05:00 endstream endobj startxref %PDF-1.5 Download Enrollment Forms. Step 1 Begin by downloading the form in Adobe PDF and opening it up in the PDF reader of your choice.
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