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Wellmed Prior Authorization Forms PDF 2012-2023
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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