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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...
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