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   Prior Authorization Request Form - Other

For authorization requests providers may but are not required to submit an authorization request to CareCentrix using this form.
If you elect to use this form, please fax the completed form to

Health Plan Fax Number
Fallen 1-866-536-3618
Florida Blue 1-877-627-6688
Florida Blue Sleep 1-855-243-3334
Horizon 1-866-522-8555
Mass General Brigham Health Plan 1-866-536-8046

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