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If you do not have a physical copy of the TDI Standard Prior Authorization Request Form for Health Care Services form already filled out, please click here to submit our full form online.

Submissions & Attachments

Patient Name*
Where you would like the confirmation email sent to print or store for your records (all submitted fields included)?
Today's Date*

Attachments

Please attach supporting clinical records to validate this request.
PLEASE INCLUDE TDI Standard Prior Authorization Request Form for Health Care Services.

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