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Get and Sign Fl Authorization Form

Get and Sign Florida Authorization Form

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Name Phone Fax SERVICING PROVIDER / FACILITY INFORMATION Same as Requesting Provider Servicing NPI * Servicing TIN * Servicing Provider/Facility Name Servicing Provider Contact Name Phone Fax AUTHORIZATION REQUEST Primary Procedure Code Start Date OR Admission Date (CPT/HCPCS) (MMDDYYYY) (Modifier) Additional Procedure Code End Date OR Discharge Date (CPT/HCPCS) (MMDDYYYY) (Modifier) * Diagnosis Code * (ICD-9) INPATIENT SERVICE TYPE * (Fill in the square with an...
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