-2017-2018-MCP-authorization-form-FINAL Accessible PDF-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the patient's name in the designated field, followed by the parent or guardian's name.
3. Fill in the address, city, and state of the patient. Ensure that all information is accurate for proper processing.
4. Indicate the language spoken at home and provide details about gestational age at birth in weeks and days.
5. Complete the requesting provider's information, including their name, address, phone number, and NPI/DEA number.
6. Document the current weight of the patient along with the date it was obtained.
7. Select any applicable medical conditions from the provided options and list any medications being administered.
8. Finally, ensure that you sign and date the form before submitting it via fax to the appropriate contact as indicated.

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