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Get and Sign Blue Cross of Idaho Additional Services Requested Form Fillable PDF 2013-2022
Documenting the clinical indications or medical necessity to the appropriate fax number listed
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below. For questions regarding this form, please call 208-331-7535 or 800-743-1871.
• lease submit all elective prior authorization requests at least 10 days prior to the scheduled date of service.
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• f the request is medically URGENT please check here ______ Reason for medical Urgency: ______________________________________________________
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• ehavioral Health: Fax 208-387-6840
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