INPATIENT Complete and Fax to: [removed]Prior Authorization Fax Form - Superbill - Document - PDFSEARCH.IO

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	INPATIENT Complete and Fax to: [removed]Prior Authorization Fax Form Add to Reading List Document Date: 2013-11-13 15:03:05 Open Document File Size: 675,40 KB Share Result on Facebook Company Granite State Health Plan Inc. / / Facility Facility Name Servicing Provider Contact Name Phone Fax AUTHORIZATION REQUEST Primary Procedure Code / FACILITY INFORMATION Same / / MedicalCondition injury / pain / illness / / / Position REQUESTING PHYSICIAN / / SocialTag Medical informatics Data privacy Health Insurance Portability and Accountability Act Privacy law Healthcare Common Procedure Coding System ICD-10 International Statistical Classification of Diseases and Related Health Problems Service Superbill Medicine

INPATIENT Complete and Fax to: [removed]Prior Authorization Fax FormAdd to Reading List