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Get and Sign Inpatient Prior Authorization Fax Form PDF Sunshine State Health

Get and Sign Inpatient Prior Authorization Fax Form PDF Sunshine State Health

Use a Inpatient Prior Authorization Fax Form PDF Sunshine State Health 0 template to make your document workflow more streamlined.

Requesting Provider Contact Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI Servicing Provider/Facility Name AUTHORIZATION REQUEST Primary Procedure Code Start Date OR Admission Date CPT/HCPCS Modifier Additional Procedure Code End Date OR Discharge Date Diagnosis Code ICD-9 INPATIENT SERVICE TYPE Fill in the square with an X Delivery C-Section Vaginal Delivery Medical Premature/False Labor Sub Acute Hospital Rehab Surgical Skilled Nursing...
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