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Silverback Authorization Form

Silverback Authorization Form

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Services Ambulatory Surgery Center Advance Care Planning MOST ICD-10 CM Diagnosis Description ICD-10 CM Code Procedure CPT/HCPCS Exact Description CPT/HCPC Code Describe any special circumstances which should be considered when authorizing services Clinical Information You may attach additional clinical This request will be treated as per the standard organization determination timeframes. If the request needs to be treated as expedited clinical justification must be provided that applying the...
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