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984![UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Arixtra – Non-Traditional Medicaid (fondaparinux sodium) Patient name:__________________________________________Medicaid ID #:______________________________ UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM Arixtra – Non-Traditional Medicaid (fondaparinux sodium) Patient name:__________________________________________Medicaid ID #:______________________________](https://www.pdfsearch.io/img/42f08ef4eafd1d88c5d44b6352ae3bec.jpg) | Add to Reading ListSource URL: medicaid.utah.govLanguage: English - Date: 2014-08-07 16:26:15
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