*REQUIRED FIELDS Pre-Authorization Request Form

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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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