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 Denver Health Prior Authorization Form 2013-2023

Denver Health Prior Authorization Form 2013-2023

Use a denver health api 2013 template to make your document workflow more streamlined.

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...
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