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Physician Certification Request for Expedited Review (Not available for care or services already provided) Illinois Department of Insurance This form is to be completed by the treating physician when the covered person h
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Document Date: 2015-02-19 17:06:45


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File Size: 58,58 KB

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National Provider / /

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Organization

Illinois Department / Insurance Office / /

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Position

Physician / treating physician / /

ProvinceOrState

Illinois / /

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