Request Submission Date:
Date of Birth:
By signing below, I certify that applying the standard review timeframe for this service request may seriously jeopardize the life or
health of the patient or the patient's ability to regain maximum function.
Clinical justification for expedited review:
Outpatient Treatment Request
Fax completed form to: 866-949-4846 Fill out completely to avoid delays
Standard Expedited (Check one): (additional information required below):
Provider Attestation (Expedited Requests Only)
Physician/clinician name: Signature:
City: State: Zip:
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