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PLEASE PRINT OR TYPE SECTION 1. IDENTIFYING …

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(Following is the required minimum information for Request of Authorization (LAC 40:2715 (C)) History provided to the level of condition and as provided by Medical Treatment Schedule Physical Findings/Clinical Tests P Faxed Emailed Faxed Emailed Faxed I hereby certify that this completed form and above required information was

  Information, Treatment

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