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Iu Health Prior Authorization Form 2014-2023
Disclaimer applies for exigent circumstances. Expedited review may also be requested when you are undergoing a current course of treatment using a non-formulary drug. Demographics Patient Information Prescriber Information Patient Name: Prescriber Name: DOB: Age: NPI#: Health Plan ID#: Pharmacy Name: Pharmacy Phone: Specialty: Phone: Fax: Office Contact: Direct Phone # or Ext: Medication Information Drug Requested: Strength: Quantity Dispensed: Day...Show details
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