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 Illinois Public Aid Prior Authorization Form 2015-2023

Illinois Public Aid Prior Authorization Form 2015-2023

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Requirements by drug at Patient information (required): Prescriber information (required): Name: Name: DOB: Phone: Fax: Nine-Digit HFS Recipient #: NPI #: Pharmacy information (required only when pharmacy is the requesting provider): Pharmacy Name: Contact person for this request (required): Name: Phone: Phone: Fax: Fax: NPI #: Medication: Strength: NDC# (if available): Effective begin date: Refills: Quantity: New prescription Renewal Directions...
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