For other uses, see Dominic (disambiguation). Dominic is a name common among Roman Catholics and other Latin-Romans as a boys name. Originally from the late Roman-Italic name Dominicus its translation means Of Our Lord, Lordly, Belonging to God or of the Master.
ï· Call us at 1-888-693-3211. ï· Fax an eviCore healthcare request form (available online) to 1-888-693-3210. Also, to ease the administrative burden of requiring prior authorization of OB Ultrasound studies, providers may batch service requests for up to 12 weeks and cases may be reviewed retrospectively for.
MEDICATION PRIOR AUTHORIZATION REQUEST FORM. IlliniCare Health Plan, Illinois. (Do Not Use This Form for Biopharmaceutical Products*) FAX this completed form to 866 -399-0929. ORCall 800-460-8988 to request a 72-hour supply of medication.Mail requests to: US Script PA Dept / 2425 West Shaw Avenue / Fresno, CA 93711.