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Scott & White Health Plan Form
Prior Authorization Request for Health Care Services Form to request services. To facilitate processing, it is critically important to provide the requesting provider and servicing provider and their location addresses below. Please note any information missing, left blank or illegible may delay the review process. PLEASE SEND CLINICALS ALONG WITH PRIOR AUTHORIZATION REQUEST. FAILURE TO PROVIDE CLINICALS MAY DELAY TIMELY REVIEW OF PRIOR AUTHORIZATION UP TO AND INCLUDING DENIAL. ☐Medical...Show details
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