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308203ALL0923‐A GCA080XHH. Prescriber quick reference guide. CenterWell Pharmacy/CenterWell Specialty Pharmacy. CenterWell Pharmacy®(mail‐delivery pharmacy for maintenance medications and durable medical equipment) 800‐379‐0092 (Fax: 800‐379‐7617), Monday – Friday, 8 a.m. – 11 p.m., and Saturday, 8 a.m. – 6:30 p.m., Eastern time. Prescribers with questions may call 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Prescribers in Puerto Rico should call 1-866-488-5991. 7671ALL0419-B . GHHKF7REN . Author: Michelle Avery Created Date:1-800-555-2546 Fax: 1-877-486-2621 to 11 p.m. Humana Pharmacy (mail order for ... Pharmacy Please call 1-800-626-2741 to join Humana’s network of pharmacy providers.With pdfFiller, an all-in-one online tool for professional document management, it's easy to fill out documents. Over 25 million fillable forms are available on our website, and you can find the 1-800-555-2546 fax to 1-877-486-2621 in a matter of seconds. Open it right away and start making it your own with help from advanced editing tools. Brand Zytiga will continue to be covered and can be filled for the patient if he or she meets prior authorization criteria. Prescribers with questions regarding this change may call 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Prescribers in Puerto Rico should call 1-866-488-5991. As of Dec. 1, 2018 ...

In today’s fast-paced business world, maintaining a strong brand image is crucial for success. One powerful tool that can help enhance your brand image is a 1-800 phone service. Ha...Plan/Medical Group Phone#: 1-800-555-2546 Plan/Medical Group Fax#: 1-877-486-2621 Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request.Humana-universal-prior-authorization-form.pdf - PRIOR AUTHORIZATION REQUEST FORM EOC ID: Admin - State Specific Authorization Form 43 Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient.Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.In today’s fast-paced digital world, businesses need to ensure that their customer service is top-notch and easily accessible. One way to achieve this is by utilizing 1-800 phone n...Finding an affordable apartment that fits your budget can be a challenging task. However, with a budget of $800 for rent, there are still plenty of options available to you. By max...800-555-CLIN (800-555-2546) Psychotropic informed consent ... 800-526-1491), Monday through Friday, 8 a.m. to 5 p.m., Eastern time. Humana recognizes that your patients have the sole discretion to choose their pharmacy. Also, we support your independent medical judgment when advising patients about their pharmacy choices. Other pharmacies are …

800-555-CLIN (800-555-2546) Psychotropic informed consent • Informed consent must accompany prescriptions for psychotropic drugs when prescribed for children younger than 13. • Find the consent form here Hemophilia Opioids • For the treatment of opioid dependency, some medication-assisted treatment (MAT) products areBakery business plan - 800 555 2546. Humana clinical pharmacy review 1-877-486-2621 (fax) .humana.com universal fax form for drug authorization patient information patient name: sex: m f subscriber id# physician information date of birth: home phone: ( ) … Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991. 1-800-555-2546 1-877-486-2621. 3 of 3 Section VI – Prescription Compound Drug Information Compound Drug Name: Ingredient NDC # Quantity Ingredient NDC # Quantity .Your health care provider can contact HCPR at 1-800-555-2546 between 8 a.m. – 8 p.m. EST, Monday – Friday to request an approval. Please allow 24 hours for Humana to review and provide a response back to your health care provider. You can find out if your medicine has any additional requirements or limits by looking in the Preferred Drug List that begins …

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The 800 mark on silver refers to the purity of the metal. Pure silver has a 1,000 grade value. Silver with an 800 grade value is a silver alloy containing 800 parts silver and 200 ...Nov 22, 2023 · If you have a Humana Medicare Advantage plan, you may contact the Humana Clinical Pharmacy Review at 1-800-555-2546 or the Customer Care phone number on the back of your Humana ID card to request coverage for any medication not on Humana’s list of covered drugs. 1-800-555-2546 1-877-486-2621. 3 of 3 Section VI – Prescription Compound Drug Information Compound Drug Name: Ingredient NDC # Quantity Ingredient NDC # Quantity . Section VII – Prescription Device Information . Requested Device Name: Expected Duration of Use: HCPCS Code (If applicable): Find out who owns 8005552546 phone number. (800) 555-2546 is a phone number on a Toll-free device.. Free owner details for (800) 555-2546.

Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991. In today’s digital age, having a reliable and professional phone number is crucial for businesses. One popular option is a 1-800 phone number. These toll-free numbers not only make...Phone: 1-800-555-2546 Fax to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for prior authorization require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.(800)9i3-7697 DAYS SUPPLY: 180 QTY: 1000 ML REFILLS: 0.000 EXP 5/29/2021 PROLIA SOL 60MG/ML (Denosumab Inj Soln Prefilled Syringe 60 569 - Provide Notice: Medicare A6 This medication may be covered DAYS SUPPLY IS MORE THAN ALLOWED BY PLAN SUBMIT VALUE < OR go PA REQD #800-555-2546 DETERMINE B OR D USE PAC …• Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546) (TTY: 711) between 8 a.m – 8 p.m Eastern time, Monday - Friday. For a member in Puerto Rico, your healthcare provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m – 8 p.m, Monday - Friday. The coverage exception request will be reviewed and our …If a member requires medically necessary services from a nonparticipating provider, the provider may call the Provider Services Contact Center to obtain prior authorization at 855-223-9868 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. Central time to obtain prior authorization. Oklahoma Medicaid pharmacy PA request form.Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in Puerto Rico should call 866-488-5991.Call 1-800-555- 2546 with questions about a customer's prior authorization for a prescription. Ray Ban Xlt 200 800 555 2546 Cafe San Francisco | Flour Bakery All ray ban xlt 200 800 555 2546 cafe san francisco at your affordable price. sunglasses really good, quality stuff, very comfortable to wear, praiseThe oakley ...Your doctor can call HCPR at (800) 555 -2546 or fax the request to (877) 486 - 2621. HCPR is available 8 a.m. to 8 p.m. local time, Monday through Friday. Or you can talk to your …If a member requires medically necessary services from a nonparticipating provider, the provider may call the Provider Services Contact Center to obtain prior authorization at 855-223-9868 (TTY: 711), Monday through Friday, 8 a.m. to 5 p.m. Central time to obtain prior authorization. Oklahoma Medicaid pharmacy PA request form.

P: 866-610-2773 P: F: 866 610 2775 Healthy Blue . by Blue Choice of SC . P: 844-345-2803 . F: 866 494 9927 Humana Healthy Horizons of SC . 800 -555 2546

1) Use code 555 in the Prior Authorization Override (NCPDP Field 462-FV) , OR 2) Call the PBM Helpdesk Absolute Total Care RX5433 844-297-0512 Pharmacies should submit “11112222333” in the PA Auth Code section of the claim. OR call PBM Helpdesk (844-297-0512) for assistance. Humana Healthy Horizons in South Carolina Molina Healthcare of SCPA for pharmacy 800-555-2546 Medicaid care management 855-223-9868 [email protected] Fraud, waste and abuse • Special Investigations Unit (SIU) Hotline: 800-614-4126 (24/7 access) • Ethics help line: 877-5-THE-KEY (877-584-3539) • Mail to: Fraud, waste and abuse Humana 1100 Employers Blvd. Green Bay, WI …3 May 2019 ... 1-800-555-2546 http://apps.humana.com/ marketing/documents.as p?file=2096263. 1-800-457-4708 docushare- web.apps.cf.humana.com/Mar keting ...• Call HCPR at 1-800-555-CLIN (1-800-555-2546) Phone number: LTC: 1-877-564-0571 MMA: 1-866-779-0565 Hours of operation: 8 a.m. – 5 p.m EST, Monday to Friday (non-holidays) Escalation contact: Elaine Blunt, RN Associate Director of Utilization Management 1-813-465-1124 Escalation contact: Melissa Perraut 1-859-628-9739 Escalation contact: …additional cost, your health care provider can contact Humana Clinical Pharmacy Review (HCPR) at 800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m. - 8 p.m. local time, Monday-Friday.1) Use code 555 in the Prior Authorization Override (NCPDP Field 462-FV) , OR 2) Call the PBM Helpdesk Absolute Total Care RX5433 844-297-0512 Pharmacies should submit “11112222333” in the PA Auth Code section of the claim. OR call PBM Helpdesk (844-297-0512) for assistance. Humana Healthy Horizons in South Carolina Molina Healthcare of SCBy calling 800-555-2546, Monday – Friday, 8 a.m. – 6 p.m., Eastern time; When applicable, please use one of the below forms when submitting an authorization request for medication or Synagis ®. Prior Authorization Request Form: Medications, PDF opens new window. Prior Authorization Request Form: Universal Synagis ®, PDF opens new windowF: 855-865-9469 F: 866-533-5493 F: 800-823-5520 Molina Humana of SC P: 855-237-6178 P: 800-555-2546 F: 855-571-3011 F: 877-486-2621 Date of Request for Authorization Patient/Member Name First Middle Last DOB City/State/Zip Medicaid Number MCO ID Number Address (Street, Apt.#) Phone800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m. - 8 p.m., Monday-Friday. How do I find a Network Pharmacy

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Todos los proveedores de Medicaid deberían contactar al estado correspondiente para cualquier consulta y servicios relacionados con Medicaid. Florida Medicaid: 800-477-6931. Illinois Medicaid: 800-787-3311. Kentucky Medicaid: 800-444-9137. Louisiana Medicaid: 800-448-3810. Ohio Medicaid: 877-856-5707. Oct 31, 2023 · To ask for a prescription drug standard decision or coverage determination, your doctor must contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546 to ask for approval. HCPR is available Monday – Friday, 8 a.m. – 8 p.m., local time. If you have a Humana plan, your prescriber can call the Humana Clinical Pharmacy Review at 800-555-2546, Monday – Friday, 8 a.m. – 8 p.m., Eastern time. If you choose to pay for a drug out of pocket, there are still ways to save. Changes to Humana’s drug formulary. Humana’s Medicare formulary updates each year.BUSINESS - New Media Communication. Bakery business plan - 800 555 2546. Bakery business plan doc - gcc tbc. Bakery business plan pdf - senarai semak pengesahan pelantikan. Bakery business plan pdf - tcc001 sars live copy form. Bakery business plan pdf in south africa - 956212nd WattKing B.ground. - isitfair co.800-555-2546. In Puerto Rico, the prescriber can call 866-488-5991. Humana’s ank Identification Number (BIN) and Processor Control Number (PCN) combinations are the following: If you have questions, please call the pharmacy call center help desk 24 hours a day, seven days a week at 800-865-8715. BILine of business N PCNYour doctor can call HCPR at (800) 555 -2546 or fax the request to (877) 486 - 2621. HCPR is available 8 a.m. to 8 p.m. local time, Monday through Friday. Or you can talk to your …Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process.In today’s fast-paced world, customer service is a crucial aspect of any business. When it comes to telecommunications, having reliable customer service is even more important. The...1) Use code 555 in the Prior Authorization Override (NCPDP Field 462-FV) , OR 2) Call the PBM Helpdesk Absolute Total Care RX5433 844-297-0512 Pharmacies should submit “11112222333” in the PA Auth Code section of the claim. OR call PBM Helpdesk (844-297-0512) for assistance. Humana Healthy Horizons in South Carolina Molina Healthcare of SCFind out who owns 8005552546 phone number. (800) 555-2546 is a phone number on a Toll-free device.. Free owner details for (800) 555-2546.Prescribers with questions regarding this change may call the Humana Clinical Pharmacy Review team at 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m., Eastern time. In Puerto Rico, call 1-866-488-5991, Monday through Friday, 8 a.m. to 8 … ….

• Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546). The coverage determination decision will be reviewed based upon medical necessity and our decision communicated within 24 hours after the request is received from the heathcare provider. Some covered medicines may have additional requirements or limits on coverage.Brand-name Spiriva with HandiHaler will continue to be covered and can be filled for your patients. Prescribers with questions regarding this change can call 800-555-CLIN (2546), Monday ─ Friday, 8 a.m. ─ 8 p.m., Eastern time. Prescribers in …• Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546) (TTY: 711) between 8 a.m – 8 p.m Eastern time, Monday - Friday. For a member in Puerto Rico, your healthcare provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m – 8 p.m local time, Monday – Friday. The coverage request will be reviewed and our …PRIOR AUTHORIZATION REQUEST FORM EOC ID Administrative Product - Universalr r rPhone 800-555-2546 Fax back to 1-877-486-2621 HUMANA INC manages the pharmacy drug benefit for your patient. Certain requests for coverage require review with the prescribing physician* Please answer the following questions and fax this form to the …Fax: 1 (800) 555-2546; Phone: 1 (877) 486-2621; Humana Universal Prior Authority Form; By State. Arcadia; California; Coal; Louisiana; Medicare Coverage (all States) Mississippi; Oklahama; Texas; How the Compose. Step 1 – Enter which patient’s full appoint, their member numbers, their group number, their complete local.... 800-555-2546 Pharmacies and technicians available for member questions Refill reminders via phone or email. Laboratory and Prescription Home Delivery Service ... Todos los proveedores de Medicaid deberían contactar al estado correspondiente para cualquier consulta y servicios relacionados con Medicaid. Florida Medicaid: 800-477-6931. Illinois Medicaid: 800-787-3311. Kentucky Medicaid: 800-444-9137. Louisiana Medicaid: 800-448-3810. Ohio Medicaid: 877-856-5707. Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process. 800-555-2546, You may also ask us for a coverage determination by phone at 1-800-555-2546 or through our website at . ... Llame al <1-800-787-3311>. La llamada es gratuita. , Lookup phone numbers & find out more about who is calling you. 411. 411 reverse phone lookup service is free. Enter a phone number, search and find the phone owner’s full name, address and more. Find out who called you., Plan/Medical Group Phone#: 1-800-555-2546 Plan/Medical Group Fax#: 1-877-486-2621. Instructions: Please fill out all applicable sections on both pages completely and legibly. Attach any additional documentation that is important for the review, e.g. chart notes or lab data, to support the prior authorization request. How did the patient receive ..., • Call Humana Clinical Pharmacy Review (HCPR) at 800-555-CLIN (800-555-2546). For drugs delivered/administered in physician’s office, clinic, outpatient or home setting (fee-for-service providers only):, Prescribers with questions regarding this change may call the Humana Clinical Pharmacy Review team at 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m., Eastern time. In Puerto Rico, call 1-866-488-5991, Monday through Friday, 8 a.m. to 8 …, To learn more, call Availity at 1-800-282-4548 or visit Availity.com. Availity provides the following functions: ... 1-800-555-2546 Fax: 1-877-486-2621 to 11 p.m. Humana Pharmacy (mail order for maintenance medications) 1-800-379-0092 Fax: 8 a.m. 1-800-379-7617 Monday through Friday, ..., 800-555-CLIN (800-555-2546) Psychotropic informed consent ... 800-526-1491), Monday through Friday, 8 a.m. to 5 p.m., Eastern time. Humana recognizes that your patients have the sole discretion to choose their pharmacy. Also, we support your independent medical judgment when advising patients about their pharmacy choices. Other pharmacies are …, Plan/medical group phone number: 1-800-555-2546 . Plan/medical group fax number: 1-877-486-2621 Urgent 1 Nonurgent Requested drug name: Patient information Prescribing provider information Patient name: Prescriber name: Member number: Prescriber fax number: Policy/group number: Prescriber phone:, 1‐800‐555‐2546. Improving or maintaining physical health: Patients report whether their physical health is the same as or better than expected in the past two years. • Applaud your patients’ physical health when possible, and encourage them to stay positive., Department Contact Phone Number: 1-800-555-2546 (CLIN) Humana is an American health insurance company based in Kentucky. As of 2014, Humana had more than 13 million members in the US. In 2018, they ranked as number 56 on the Fortune 500 list, which made them the highest ranked company that is based in Kentucky. Humana is offering their …, 877-486-2621 800-555-2546 Important addresses Humana department Address Provider correspondence Humana, Attn: Provider Correspondence P.O. Box 14601 Lexington, KY 40521-4601 Provider complaints Humana, Attn: Provider Complaints P.O. Box 14601 Lexington, KY 40521-4601 Member grievances and appeals Humana Health Plans P.O. …, If you own a Polaris RZR 800, you probably already know what an incredible off-road vehicle it is. With its powerful engine, rugged design, and exceptional performance, the Polaris..., FL MMA: 1-800-477-6931: IL ICP: 1-800-764-7591. Humana Clinical Pharmacy Review (HCPR) 1-800-555-CLIN (1-800-555-2546) U.S. fax: 877-486-2621. Puerto Rico HCPR phone: ..., 800-555-CLIN (800-555-2546) Psychotropic informed consent • Informed consent must accompany prescriptions for psychotropic drugs when prescribed for children younger than 13. • Find the consent form here Hemophilia Opioids • For the treatment of opioid dependency, some medication-assisted treatment (MAT) products are, Humana-universal-prior-authorization-form.pdf - PRIOR AUTHORIZATION REQUEST FORM EOC ID: Admin - State Specific Authorization Form 43 Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient., Provider Payment Integrity 1-800 438 7885 Refer to information provided in your overpayment letter. ... Phone: 1-800-555-2546 Fax: 1-877-486-2621 Provider Quick …, Phone: 1-800-555-2546 Fax back to: 1-877-486-2621 Humana manages the pharmacy drug benefit for your patient. Certain requests for coverage require additional information from the prescriber. Please provide the following information and fax this form to the number listed above. Information left blank or illegible may delay the review process., For a medicine requiring prior authorization, there are two simple steps. Ask your prescriber to provide authorization. Then, have your provider call CenterWell Clinical Pharmacy Review at 800-555-CLIN (800-555-2546), Monday – Friday, 8 a.m. – 8 p.m. or submit a prior authorization request online. , Brand Ventolin HFA will continue to be covered and can be filled for the patient. Prescribers with questions regarding this may call 1-800-555-CLIN (1-800-555-2546), Monday through Friday, 8 a.m. to 8 p.m. Eastern time. Prescribers in Puerto Rico should call 1-866-488-5991. On January 1, 2020, generic Ventolin HFA (albuterol HFA) will be ..., Humana Clinical Pharmacy Review (HCPR) 1-877-486-2621 P.O. Box 14601 Lexington, KY 40512. You may also ask us for a coverage determination by phone at 1-800-555-2546 …, To ask for a prescription drug standard decision or coverage determination, your doctor must contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546 to ask for approval. HCPR is available Monday – Friday, 8 a.m. – 8 p.m., local time., 800-555-2546. For Puerto Rico prior authorizations only, please call 866-488-5991. Improving or Maintaining Physical Health¹ Patients report whether their physical health is the same as or better than expected in the past two years. • Praise your patients’ physical health when possible and encourage them to stay positive., To ask for a prescription drug standard decision or coverage determination, your doctor must contact Humana Clinical Pharmacy Review (HCPR) at 1-800-555-2546 to ask for approval. HCPR is available Monday – Friday, 8 a.m. – 8 p.m., local time. Your doctor also can use tools available on Humana.com/Providers., , If you own a Polaris RZR 800, you probably already know what an incredible off-road vehicle it is. With its powerful engine, rugged design, and exceptional performance, the Polaris..., Member/Provider Services contact center. 855-223-9868 (TTY: 711) Monday through Friday, 8 a.m. to 5 p.m., Central time. Member 24-hour nurse advice line (available 365 days a year) 800-854-6619. Provider Relations. [email protected]. Humana Healthy Horizons in Oklahoma is a Medicaid product of Humana Wisconsin Health ... , Lookup phone numbers & find out more about who is calling you. 411. 411 reverse phone lookup service is free. Enter a phone number, search and find the phone owner’s full name, address and more. Find out who called you., To use PeepLookup, simply enter the phone number in the dialpad below and click on lookup. We will then provide you with the full name of the person who owns the phone number. PeepLookup works on both cell phones and landline phones. It is the best reverse phone lookup free. You do not need credit card to use PeepLookup., care provider can contact Humana Clinical Pharmacy Review (HCPR) at 800-555-2546 (TTY: 711) between 8 a.m. – 8 p.m. Eastern time, Monday – Friday. For a member in Puerto Rico, your health care provider can contact HCPR in Puerto Rico at 866-488-5991 between 8 a.m. - 8 p.m., Monday-Friday. How do I find an in-network Pharmacy?, However, with our preconfigured web templates, everything gets simpler. Now, using a 800 555 2546 requires not more than 5 minutes. Our state-specific online samples and complete recommendations eliminate human-prone errors. Follow our simple steps to have your 800 555 2546 prepared quickly: Pick the template from the catalogue. , 1) Use code 555 in the Prior Authorization Override (NCPDP Field 462-FV) , OR 2) Call the PBM Helpdesk Absolute Total Care RX5433 844-297-0512 Pharmacies should submit “11112222333” in the PA Auth Code section of the claim. OR call PBM Helpdesk (844-297-0512) for assistance. Humana Healthy Horizons in South Carolina Molina Healthcare of SC, Coverage Determination (Prior Authorization) Phone: 1-800-555-2546. Coverage Determination (Prior Authorization) Fax: 1-877-486-2621. Redetermination (First Level Appeal) Form. Redetermination Appeal Phone: 1-877-320-1235. Redetermination Appeal Fax: 1-866-556-2128. Expedited Redetermination Appeal Phone: 1-800-867-6601, F: 855-865-9469 F: 866-533-5493 F: 800-823-5520 Molina Humana of SC P: 855-237-6178 P: 800-555-2546 F: 855-571-3011 F: 877-486-2621 Date of Request for Authorization Patient/Member Name First Middle Last DOB City/State/Zip Medicaid Number MCO ID Number Address (Street, Apt.#) Phone