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*REQUIRED FIELDS Pre-Authorization Request Form

www.kernlegacyhp.com

URGENCY OF REQUEST: Standard – 5 days Urgent – 3 days Emergency – 24 hours KERN LEGACY HEALTH PLAN Employee and Retiree Health Plan Options Pre-Authorization Request Form 1115 Truxtun Ave, 1st Floor | Bakersfield CA 93301 | Ph: 661 868-3280 |UM Fax: 661 868-3291 | www.kernlegacyhp.com Kern Legacy Health Plan – Authorization Request Form

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Texas Standard Prior Authorization Request Form for Health ...

www.bcbstx.com

Title: Texas Standard Prior Authorization Request Form for Health Care Services Author: Texas Department of Insurance Keywords: prior authorization request form, NOFR001, SB 1216

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AltaMed Authorization Request Form

www.altamed.org

ALTAMED AUTHORIZATION REQUEST FORM URGENT (72 HOURS) Requests submitted as an urgent referral when standard timeframes could seriously jeopardize the Member's life or health or ability to attain, maintain or regain maximum function. ROUTINE (5 BUSINESS DAYS)

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Prior Authorization Request Form - L.A. Care Health Plan

lacare.org

AUTHORIZATION IS CONTINGENT UPON MEMBER’S ELIGIBILITY ON DATE OF SERVICE. REV 11/20. Do not schedule non-emergent services until authorization is obtained . LA2629 12/19 *CPT / HCPCS Codes / Descriptions for service(s) REQUIRING Authorization . In-Network Specialty Referrals DO NOT require prior Auth

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Prescription Drug Prior Authorization Request Form - Aetna

www.aetna.com

Form 61-211 (Revised 12-2016) Effective 7/1/2017 Page 3 of 10 GR-69025-CA (5-17) Aetna complies with applicable Federal civil rights laws and does not discriminate, exclude or treat

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Authorization Request Form - Hopkins Medicine

www.hopkinsmedicine.org

Authorization Request Form FOR EHP, PRIORITY PARTNERS AND USFHP USE ONLY Note: All fields are mandatory. Chart notes are required and must be faxed with this request. Incomplete requests will be returned. Please fax to the applicable area: EHP & OPP DME: 410-762-5250 Inpatient Medical: 410 -424-4894 Outpatient Medical:410 -762 5205

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