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Denver Health Prior Authorization Form 2013-2023
POS
M
CHP+
Phone Number:
F
DH Medicaid Choice
DH Medicare Choice
DH Medicare Select
DERP/CSA
Insurance #:
Drug Requested:
Strength:
Qty:
Rx Directions (sig):
Comments:
DH Staff Provider?
Prescriber:
To be filled at:
Park Hill
Yes
No
DH Primary Care Pharmacy
Central Fill (mail order)
Eastside
La Casa Pharmacy
Lowry
Westside Pharmacy
ID/AIDS Clinic Pharmacy
DH Discharge Pharmacy
Clinic Fax #
Westwood
Montbello
Other _________________
Clinic Portion (May be completed by Provider...
Show details
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