Texas Standard Prior Authorization Form
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Issuer name (if different from section i): 4) request a guarantee of payment; Member or medicaid id #: Web standardized prior authorization request form for health care services (1.49 mb) 8/7/2015;
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Web molina pharmacy prior authorization department. Do not use this form to: Rx id # (if available): Web electronically, through the issuer’s portal, to request prior authorization of a health care service.