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Hf0917x065 2017-2023
Provider Fax Number: (
-
OP Behavioral Health
Contact Name:
OP Medical Care/Procedure
Requesting Provider/Facility Name:
DME/Radiology
)
-
Physician State License #:
Speech Therapy
Outpatient Surgery
Requesting Provider NPI #:
IV Therapy/Home Health
Billing Tax ID #:
Adjunctive Dental
Essential Service Information
Hospice/Respite Care
IP
*Clinical justification for Urgent priority must be attached or noted
below. If not provided, request will be processed as Routine.
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