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Medicaid Outpatient Prior Authorization Fax Form
299 Drug Testing 922 Experimental and Investigational Services 205 Genetic Testing & Counseling 290 Hyperbaric Oxygen Therapy 141 Imaging 112 Nutritional Supplements and/or Services 279 Occupational Therapy Evaluation 101 Physical Therapy. 127 Speech Therapy Evaluation (nonpar only) 701 Speech Therapy 790 Occupational Therapy. City, State, Zip
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