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Prior Authorization and Informal Review Form
I am asking the Internal Affairs Office to Informally review the following
Person Requesting
*
Description of what is being requested
*
Reason for request
*
Can this request be fulfilled without cost?
*
A
Yes
B
No
Is the request urgent?
*
A
Yes
B
No
Cost of the request
*
Other notes for the reviewer
*
I understand all denied requests will be appealed to the Northern District of New York - Internal Affairs Office for further review.
*
Yes
Submit