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Includes patient information (name, date of birth, ID number, phone, mailing address) and provider information (provider name, signatures, office contact, phone, and fax). Requests medication, quantity/day supply, diagnosis with ICD-9 documentation support, therapy duration, history of failed drug therapies, and additional information. 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PHI is individually identifiable health information related to a person’s past, present or future physical or mental health; a provision of healthcare to that person; or the past, present, or future payment for that person’s healthcare. To the extent the information in this transmission contains PHI, you are obligated to maintain PHI in a secure and confidential manner in accordance with applicable law. If you have received this communication in error, please notify MPS Prior Authorization at 1.800.830.2310 immediately by telephone; destroy this message and any copies. Unauthorized use and/or disclosure, or failure to maintain confidentiality of PHI may subject you to penalties under applicable state and federal laws.","cbCaircxJClssz2B","https://ap.wps.com/l/cbCaircxJClssz2B","pdf",165808,"English","# Rx General Form\n## Patient Information\n## Provider Information\n## Prior Authorization Form\n## Turnaround Time and Fax Instructions\n## Plan Decision Status and HIPAA Notice","[{\"question\":\"What information is required for the patient section?\",\"answer\":\"Provide patient name, date of birth, ID number, patient phone, and mailing address.\"},{\"question\":\"What provider details are included in this form?\",\"answer\":\"Include provider name, provider signature, office contact person, office phone, and office fax.\"},{\"question\":\"Where should the completed form and supporting documentation be sent?\",\"answer\":\"Fax the completed form and supporting documentation to 763.582.3477.\"}]","Rx General Form - Prior Authorization Form | PDF"]