41![Quick Reference Drug List US Script Contact Information: Prior Authorization Phone: Prior Authorization Fax: Clinical Hours: Monday – Friday 9:00 a.m. – 7:00 p.m. CountyCare Provider Inquiry Quick Reference Drug List US Script Contact Information: Prior Authorization Phone: Prior Authorization Fax: Clinical Hours: Monday – Friday 9:00 a.m. – 7:00 p.m. CountyCare Provider Inquiry](https://www.pdfsearch.io/img/c3ab638fe1074444042affc97b8cf891.jpg) | Add to Reading ListSource URL: www.countycarehealth.comLanguage: English - Date: 2015-03-09 16:47:38
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42![Page 1 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: _Community Health Group___________ Plan/Medical Group Phone#: ( Page 1 of 2 PRESCRIPTION DRUG PRIOR AUTHORIZATION REQUEST FORM Plan/Medical Group Name: _Community Health Group___________ Plan/Medical Group Phone#: (](https://www.pdfsearch.io/img/d5661c6b0bff185cd73f0d6a0d2e6468.jpg) | Add to Reading ListSource URL: chgsd.comLanguage: English - Date: 2016-01-14 20:15:56
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43![Prior Authorization Request Form Fax this form and any supporting clinical information (office notes, Laboratory and Radiology Reports, Brief Medical History, or Treatment Plan) to: Total Care, A Today’s Options® of N Prior Authorization Request Form Fax this form and any supporting clinical information (office notes, Laboratory and Radiology Reports, Brief Medical History, or Treatment Plan) to: Total Care, A Today’s Options® of N](https://www.pdfsearch.io/img/b5c7268819da95d628d8a9e26547f5f9.jpg) | Add to Reading ListSource URL: www.totalcareny.comLanguage: English - Date: 2015-09-15 13:27:45
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44![PRIOR AUTHORIZATION REQUEST FORM EOC ID: CFI Non Formulary Exceptionr r PRIOR AUTHORIZATION REQUEST FORM EOC ID: CFI Non Formulary Exceptionr r](https://www.pdfsearch.io/img/44e4c4fe168f07cf387d79e458114f5a.jpg) | Add to Reading ListSource URL: ironworkerbenny.comLanguage: English - Date: 2016-02-03 17:56:44
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45![Prior Authorization Requirements Effective: CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both progr Prior Authorization Requirements Effective: CommuniCare Advantage Cal MediConnect Plan (Medicare-Medicaid Plan) is a health plan that contracts with both Medicare and Medi-Cal to provide benefits of both progr](https://www.pdfsearch.io/img/162c2cebe950f7f57d288f16f7b8a3b9.jpg) | Add to Reading ListSource URL: chgsd.comLanguage: English - Date: 2016-01-14 20:15:54
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46![](/pdf-icon.png) | Add to Reading ListSource URL: bfa.sdsu.eduLanguage: English - Date: 2015-11-05 12:58:29
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47![MEDICATION PRIOR AUTHORIZATION REQUEST MEDICATION PRIOR AUTHORIZATION MEDICATION PRIOR AUTHORIZATION REQUEST MEDICATION PRIOR AUTHORIZATION](https://www.pdfsearch.io/img/04d86bf44c7202058cbb41f3a3fd7c3d.jpg) | Add to Reading ListSource URL: www.countycarehealth.comLanguage: English - Date: 2015-02-25 12:00:06
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48![IMPORTANT REMINDER ! ! ! Please be aware that you are required to receive prior authorization before receiving certain services, which are listed below: The Medical Management program works closely with you and your IMPORTANT REMINDER ! ! ! Please be aware that you are required to receive prior authorization before receiving certain services, which are listed below: The Medical Management program works closely with you and your](https://www.pdfsearch.io/img/750f1dff86472b2d056e064f71d36cc7.jpg) | Add to Reading ListSource URL: www.teamsterslocal282.comLanguage: English - Date: 2014-03-21 11:18:15
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49![Patient Authorization/Consent Form Individual states may have additional informed consent requirements for this type of testing - please review your own state law requirements prior to use Patient Information Last Name Patient Authorization/Consent Form Individual states may have additional informed consent requirements for this type of testing - please review your own state law requirements prior to use Patient Information Last Name](https://www.pdfsearch.io/img/2784ef9c3aac0b3611da38aec2090416.jpg) | Add to Reading ListSource URL: www.foundationone.comLanguage: English - Date: 2015-09-28 14:38:50
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50![Prior Authorization Requirements Effective: This is not a complete list of drugs covered by our plan. For a complete and current listing, please call Member Services 24 hours a day, seven days a week at 1-888- Prior Authorization Requirements Effective: This is not a complete list of drugs covered by our plan. For a complete and current listing, please call Member Services 24 hours a day, seven days a week at 1-888-](https://www.pdfsearch.io/img/866fa6e82f3e5515e73a48fc06ab28cb.jpg) | Add to Reading ListSource URL: chgsd.comLanguage: English - Date: 2016-01-14 20:15:54
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