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Peer-to-peer request form

If this is an urgent request, please call the AmeriHealth Medical Director’s Office at 215-241-0494. For all out-of-area requests, please call 1-888-814-2244. All non-urgent calls will be returned within 24 hours.

Please complete all information requested on this form.

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Contact information

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Patient Information

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Add another patient


Requesting physician information

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Inpatient Information (if applicable)








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