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Get and Sign Complete and Fax To1 844 367 7022 2017-2022 Form

Get and Sign Complete and Fax To1 844 367 7022 2017-2022 Form

Use a silver summit authorization 2017 template to make your document workflow more streamlined.

Provider/Facility Name AUTHORIZATION REQUEST Primary Procedure Code Additional Procedure Code CPT/HCPCS Modifier OUTPATIENT SERVICE TYPE 412 Auditory Services 422 Biopharmacy 924 Chiropractic 712 Cochlear Implants Surgery 295 Dental Anesthesia 299 Drug Testing 922 Experimental Investigational Services 709 Genetic Testing 249 Home Health 290 Hyperbaric Oxygen Therapy Start Date OR Admission Date Diagnosis Code ICD-10 End Date OR Discharge Date Total Units/Visits/Days Enter the Service type...
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