Fax: (800) 869-7791 Molina Healthcare of …

27031WA0812 Molina Healthcare of washington prior authorization / medication exception request Allow 2 business days to process Fax: (800) 869-7791 Phone: (800) 213-5525 DatePatient Name (Last, First, MI)Member ID#Date of BirthPhysician Name (Last, First, MI)Phone Number Fax Number ( ) ( )Specialty NPI/DEA# medication (Name - Strength - Dose)Qty / MonthDirections for Use Duration of Use Diagnosis / Medical Indications Previous Meds Trial - Dates of UseMedical Justification Re- authorization of current medicationPharmacy Fax Number: ( ) Pharmacy: Note Effective Dates Please include your fax number.

27031WA0812 Molina Healthcare of Washington Prior Authorization/ Medication Exception Request Allow 2 business days to process

Tags:

  Medication, Request, Authorization, Washington, Healthcare, Exception, Molina, Prior, 1977, Prior authorization medication exception request molina healthcare of washington, 869 7791 molina healthcare of

Information

Related search queries