Validating PMI number . . .
Requester is encouraged to submit any additional information to support the request for appeal including, for example, clinic notes and dates of previous medication trials.
Submit your additional rationale documentation with this form.
Fax to: 612-632-8815
In case of emergency, please call 612-596-9914 immediately when request is faxed
300 South Sixth Street, MC 604
Minneapolis, Minnesota 55487-0604
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