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Get and Sign Amerihealth Authorization Form
Therapy, please include strength, frequency and duration:
Rationale and/or additional information, which may be relevant to the review of this prior authorization
request:
Prescriber Signature
Please fax this form to: 855-851-4058
PerformRx
200 Stevens Drive
Philadelphia, PA 19113
Date
PerformRx Provider Services:
Phone: 888-674-8720
Important PAYMENT NOTICE
Please note that reimbursement for all rendering network providers subject to the ordering/referring/prescribing (ORP)
requirement for...
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