Electronic Funds Transfer (EFT) Authorization Form
Electronic Funds Transfer (EFT) Authorization Form Please do not send: Detach & mail with blank voided check Electronic Funds Transfer (EFT) Authorization Form Member Number: _____ Member Name:_____
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www.aarpmedicareplans.comA non-network pharmacy located within a care institution (emergency department, provider based clinic, outpatient surgery or other outpatient facility) dispensed my medication while I was a patient. I was evacuated or displaced from my residence due to a state or federally declared disaster or health emergency.
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www.aarpmedicareplans.comIf you received this document by mistake, please know that sharing, copying, distributing or using information in this document is against the law. If you are not the intended recipient, please notify the sender immediately. Office use only: General_CMS_2019Oct-W Prior Authorization Request Form (Page 1 of 2) DO NOT COPY FOR FUTURE USE.
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