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Get and Sign Indiana Medicaid Authorization Form

Get and Sign Indiana Medicaid Prior Authorization Form

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877-647-4848 F: 866-912-4245 P: 866-398-1922 F: 866-406-2803 See P: 877-647-4848 F: 866-912-4245 P: 800-784-3981 F: 800-689-2759 P: 866-440-2449 F: 877-822-7186 Please complete all appropriate fields. Patient Information Requesting Provider Information: Medicaid ID/RID#: NPI#: DOB: Tax ID#: Patient Name: Service Location Code: Address: Provider Name: City/State/Zip: Rendering Provider Information Patient/Guardian Phone: Ordering Physician NPI#: PMP Name: Tax...
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Instructions and help about coverage programs authorization

Let's walk through an example of an EPA request that requires additional information on your part in order to complete the process double-click on the to-do-list notification to open the EPA status dialog remember you can also right-click on the medication name from the face sheet and select open EPA status dialog to get here as well if you would like to cancel this EPA request you will have the option to do so from this dialog by clicking cancel process to address the prior authorization questions click the link for complete PA form located to the right of action required you will then be taken to a summary screen where you will click star in order to begin the process then answer each question and click Next to proceed if you would like to go back to the previous screen click back if you would like to cancel your answer to this question and go back to the previous screen then click release if you would like to save your answers and finish later click Save on any of the screens otherw

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