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 Wellmed Prior Authorization Forms PDF 2012-2023

Wellmed Prior Authorization Forms PDF 2012-2023

Use a wellmed prior authorization form 2012 template to make your document workflow more streamlined.

PA: ______________ **Doses above 32 mg per day will NOT be approved. 1. Primary Diagnosis: ICD-9: _______________________________________________________ 2. Psychosocial Counseling: __________________________________________________________ a. Date of last psychosocial counseling session: _______________________________________ b. Has patient been compliant with all sessions? [ ] Yes [ ] No 3. Please provide plan for method and dates (next 3) of psychosocial counseling going forward: a....
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