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Fill and Sign the Mvp Health Care Standard Nys Medicaid Prior Authorization Form

Fill and Sign the Mvp Health Care Standard Nys Medicaid Prior Authorization Form

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To: Department of Labor and Industries Claim No: ____________________________________ Please transfer my case Date (changed health care providers): __________________ ________________________________________________________________________________ From: (Name of provider) ________________________________________________________________________________ To : (Name of new provider) Provider ID # / NPI#: ________________________________________________________________________________ Address of new provider: ________________________________________________________________________________ City: State: Zip: ________________________________________________________________________________ Reason for transfer: ________________________________________________________________________________ Claimant’s name: Today’s date: ________________________________________________________________________________ Address: ________________________________________________________________________________ City: State: Zip: ________________________________________________________________________________ Claimant’s signature: ________________________________________________________________________________ F245-037-000 Transfer of Care Card 04-2014 Index: TCARE Fax to: 360-902-4567 Or Mail to: Department of Labor and Industries Claims Section PO Box 44291 Olympia WA 98504-4291

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