Initial Authorization Request Form - Maine
Submitting Provider Return Address: Section 1: (See Section 3 for instructions) 1. Submitting Provider Name ... (For medical equipment – ... A prior authorization number does not guarantee that the PA has been medically approved or that the service will be paid.
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Physical Therapy Request for Chronic Pain Form
mainecare.maine.govDepartment of Health and Human Services MaineCare Services Prior Authorization Unit, Physical/Occupational Therapies 11 State House Station Augusta, Maine 04333-0011
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