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PA_Methadone_v1.0_20130328.xls>FOR PUBLIC COMMENT ONLY: Prior Auth Form for Methadone1.042 KB3/28/2013
PA_Methadone_v1.0_20130328.pdf>FOR PUBLIC COMMENT ONLY: Prior Auth Form for Methadone (PDF)1.073 KB3/28/2013
PA_Cover_Sheet_Update_Add_Docs_v2.0_20111021.docxCover Sheet Updates or Supporting Documents for Authorizations2.055 KB10/21/2011
PA_Cover_Sheet_Update_Add_Docs_v2.0_20111021.pdfCover Sheet Updates or Supporting Documents for Authorizations (PDF)2.078 KB10/21/2011
PA_Initial_Request_Form_v4 0_20140204.docInitial Authorization Request Form4.0118 KB2/4/2014
PA_Initial_Request_Form_v4 0_20140204.pdfInitial Authorization Request Form (PDF)4.0121 KB2/4/2014
PCCM_Referral_Request_Form_v2.0_20130208.docxPCCM Referral Request Form2.061 KB2/8/2013
PCCM_Referral_Request_Form_v2.0_20130208.pdfPCCM Referral Request Form (PDF)2.082 KB2/8/2013
PA_Request_PT_for_Chronic_Pain_v3.0_20140211.docPhysical Therapy Request for Chronic Pain Form3.066 KB2/11/2014
PA_Request_PT_for_Chronic_Pain_v3.0_20140211.pdfPhysical Therapy Request for Chronic Pain Form (PDF)3.039 KB2/11/2014
DME_Install_Replacement_Parts_v1.0_20120221.docRepair/Replacement Justification Form for DME1.0107 KB2/21/2012
DME_Install_Replacement_Parts_v1.0_20120221.pdfRepair/Replacement Justification Form for DME (PDF)1.081 KB2/21/2012
PA_Therapy_Services_Fax_Cover_v2.0_20130108.docTherapy Services Review / Fax Cover2.071 KB1/8/2013
PA_Therapy_Services_Fax_Cover_v2.0_20130108.pdfTherapy Services Review / Fax Cover (PDF)2.0104 KB1/8/2013
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