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Validating PMI number . . .

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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.

    For Hennepin Health Use Only

    Fax to: 612-632-8815

    In case of emergency, please call 612-596-9914 immediately when request is faxed

    Hennepin Health

    300 South Sixth Street, MC 604 

    Minneapolis, Minnesota 55487-0604

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