anthem prior authorization form pdf

2005 - 2022 copyright of Anthem Insurance Companies, Inc. stream provider manual identification card. endstream endobj 22 0 obj <>stream SOMOS Prior Authorization Form (Behavioral Health) SOMOS Prior Authorization Form (Medical) SOMOS UB-04 Medical Claim Form. Medicare Advantage Outpatient Pre-Treatment Authorization Program (OPAP) Request Form. There are three variants; a typed, drawn or uploaded signature. The Blue Cross name and symbol are registered marks of the Blue Cross Association. 18 0 obj <> endobj Please Select Your State The resources on this page are specific to your state. Type at least three letters and well start finding suggestions for you. Forms. Prior to June 2022, Elevance Health was named Anthem, Inc. Page1 of3 Anthem Utilization Management Services, Inc. Browse our forms library for documentation on various topics including pharmacy, . Log in to Availity ; g`e`(ed@ A(&Z cq*QSSg0v A3*G2KB Our resources vary by state. 2 0 obj Prior Authorization. Then select the Documents tab to combine, divide, lock or unlock the file. Step 9 At the top of page 2, provide the patients name and ID number. To request prior authorization, contact Companion Benefits Alternatives (CBA) using one of the below options: Calling 800-868-1032 Forms Resource Center - This online tool makes it easy for behavioral health clinicians to submit behavioral health prior authorization requests. Choose the correct version of the editable PDF form from the list and get started filling it out. Do not sell or share my personal information. April 2017. Draw your signature, type it, upload its image, or use your mobile device as a signature pad. Create an account using your email or sign in via Google or Facebook. BlueRx Drug Prior Authorization BlueRx Physician Drug Authorization Request Form BlueRx Drugs Drug Coverage Determination, Formulary or Tier Exception Drug Authorization Forms, Quantity Limit Drug Authorization Form and Step Therapy Drug Authorization Forms Related Information: Forms & Manuals Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). 24/7 online access to account transactions and other useful resources, help to ensure that your account information is available to you any time of the day or night. Forms | Blue Cross and Blue Shield of Illinois Forms The forms in this online library are updated frequently check often to ensure you are using the most current versions. Your browser is not supported. 2022 copyright of Anthem Insurance Companies, Inc. Medicare BH Psych Testing Form: PDF: Medicare Level I Appeals: PDF: Member Appeal Representation Authorization Form: PDF: Prime Therapeutics - Pharmacy Fax Order Form: PDF: Post Service - Ambulance Trip Sheet Form: PDF: Post Service - Dermatology Patch Allergy Testing Form: PDF: Post Service - Hemodialysis Treatment for ESRD Form: PDF For more information on OhioRISE, call their toll-free number, contact your provider services representative, or visit their site at Once an account has been created, providers can securely access Medicaid's enterprise systems. Behavioral Health (Outpatient - ABA) Service Authorization Request. Companies, Inc. ANVPEC-1497-20 December 2020 Please check the appropriate box below and send only the corresponding authorization type to that fax number. Looking for a form but don't see it here? We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Top. The form contains important contact regarding the patient's medicinal history and requested medications which Anthem is use to determine if or not one prescription is inserted in the patient's health caution plan. Some drugs, and certain amounts of some drugs, require an approval before they are eligible to be covered by your benefits. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. Any incomplete sections will result in a delay in processing. . -iKHs8@jGL&iM`jgg`, |F5 j& Looking for a form, but don't see it here? Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. Begin automating your signature workflows right now. However, if you would like to submit a request for preauthorization after contacting PRS, you may submit a written request by completing this form. To check the status of a prior authorization request or decision for a particular plan member, or to submit a clinical appeal, providers will access our Interactive Care Reviewer (ICR) tool via Availity Essentials. 02. Choose your location to get started. It looks like you're outside the United States. During this time, you can still find all forms and guides on our legacy site. It looks like you're outside the United States. Draw your signature or initials, place it in the corresponding field and save the changes. Our prior authorization team is available from 8 a.m. - 9 p.m. Anthem has also made available a series of forms for specific medications which may provide more efficient service when making a request. Please be advised the general phone number may lead to longer hold times. How to Write Step 1 - At the top of the form, supply the plan/medical group name, plan/medical group phone number, and plan/medical group fax number. -1!o7! ' ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. <> Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023. . card. Use a anthem prior authorization form pdf 2018 template to make your document workflow more streamlined. . Drug Forms | Blue Cross and Blue Shield of Texas Prescription Drug Forms The following prescription drug forms are available as PDF files. Anthem Hoosier Healthwise P: 866-408-6132 F: 866-406-2803 CareSource Hoosier Healthwise P: 844 -607 2831 F: 432 8924 P: 888 -961 3100 F: 465 5581 Lastly, give the name of an office contact person along with the corresponding phone number, fax number, and email address. Step 5 In Medication / Medical and Dispensing Information, specify the medication name and indicate whether or not the request is a new therapy or a renewal (if renewal, specifythe date therapy started and the duration). Required clinical information - Please provide all relevant clinical information to support a prior authorization review. O4 Footer Nav. Go to the Chrome Web Store and add the signNow extension to your browser. Select the area you want to sign and click. Health insurance can be complicatedespecially when it comes to prior authorization (also referred to as pre-approval, pre-authorization and pre-certification). Medical necessity denials that are provider write-offs. Support > Forms > Prior Authorization Forms > Request for Preservice Review. 4 0 obj If your state isn't listed, check out bcbs.com to find coverage in your area. Install the signNow application on your iOS device. Inpatient and Outpatient Authorization Request Form. Sign it in a few clicks. You can also visit bcbs.com to find resources for other states. The Blue Cross name and symbol are registered marks of the Blue Cross Association , The Prescription Drug Prior Authorization Or Step Therapy Exception Request Form. Portal Guides. Prior authorization form notification Sep 1, 2021 State & Federal / Medicare The best way to ensure you're submitting everything needed for a prior authorization is to use the prior authorization/precertification form at anthem.com/medicareprovider > Providers > Provider Resources > Forms and Guides. Enrollment/Discharge/Transfer (EDT) State Hospitals and 590 Program - State Form 32696 (R3/2-16)/OMPP 0747. ET By fax: Request form Members All Member Forms endobj Step 7 In Medication / Medical and Dispensing Information, specify the following prescription details: dose/strength, frequency, length of therapy/number of refills, and quantity. Fax numbers and mailing addresses are on the forms. Surgery and/or outpatient procedures How can my provider request prior review and certification? Below that, write the name of the requester (if different than the prescriber) and supply the prescribers NPI number and DEA number. Select Your State If allowed amounts disagree with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials. Please contactyourproviderrepresentative for assistance. If you can't submit a request via telephone, please use our general request form or one of the state specific forms below and fax it to the number on the form. You will find this number on your member identification We look forward to working with you to provide quality service for our members. With signNow, you cane Sign as many files in a day as you need at a reasonable price. We currently don't offer resources in your area, but you can select an option below to see information for that state. Title: Pre-Service Review Generic PBC Author: Premera Blue Cross Subject: Prior Authorization Form Keywords: Prior Authorization Form, Top 3 Reminders for Premera Prior Authorizations, Get a Faster Response Using Availity for Online Submission, Providers Outside of W a , a K : Choose Premera as Payer, Premera Secure Tools Transition to Availity on September 10, More Information, Pre-service . Faxing BCBSM at 1-866-601-4425. Please contactusfor assistance. Ask your provider to go to Prior Authorization Requests to get forms and information on services that may . Edit your aim prior auth form online. Calculate your savings Use the calculator below to see how much time and money Electronic Prior Authorization can save your practice. Types of Forms Appeal/Disputes Prior Authorization; Patient Care Patient Care. Add the PDF you want to work with using your camera or cloud storage by clicking on the. Some medical services and medications may need a prior authorization (PA), sometimes called a "pre-authorization," before care or medication can be covered as a benefit. %PDF-1.5 This will help in a faster turn-around-time Provider forms Provider forms Download and print commonly requested forms for prior authorizations, coverage determination requests, referrals, screenings, enrollment for electronic claims submission and remittance advices, and more. A library of the forms most frequently used by healthcare professionals. endstream endobj 24 0 obj <>stream <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S>> =upDHuk9pRC}F:`gKyQ0=&KX pr #,%1@2K 'd2 ?>31~> Exd>;X\6HOw~ . Please refer to the criteria listed below for genetic testing. External link. 2023copyright of Anthem Insurance Companies, Inc. Anthem Blue Cross and Blue Shield Medicaid is the trade name of Community Insurance Company, an independent licensee of the Blue Cross and Blue Shield Association. Serving Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri (excluding 30 counties in the Kansas City area), Nevada, New Hampshire, Ohio, Virginia (excluding the Northern Virginia suburbs of Washington, D.C.), and Wisconsin. Prior Authorization Requests for Medical Care and Medications. <> %%EOF Please contact us for assistance. If you are experiencing technical difficulties with submitting an electronic prior authorization, call to submit a verbal prior authorization. Employee Enrollment Application Change Form/Anthem Balanced Funding - Downstate (274 KB) Employee Enrollment Application Change Form/Anthem Balanced Funding - Upstate (261 KB) Provider Nomination Form - Dental (83 KB) endstream endobj startxref Dallas, TX 75266-0044. 66 0 obj <>stream Step 11 On page 2 (2), list all diagnoses and provide theICD-9/ICD-10. endobj Box 660044. Edit anthem prior authorization form pdf. Type at least three letters and we will start finding suggestions for you. Get forms; See prior authorization and appeals data. We currently don't offer resources in your area, but you can select an option below to see information for that state. Go to Sign -Sgt; Add New Signature and select the option you prefer: type, draw, or upload an image of your handwritten signature and place it where you need it. Our resources vary by state. Part B: How to generate an signature for your PDF document in the online mode, How to generate an signature for your PDF document in Chrome, How to make an electronic signature for putting it on PDFs in Gmail, The best way to make an electronic signature right from your mobile device, The best way to create an electronic signature for a PDF document on iOS devices, The best way to make an electronic signature for a PDF on Android devices, If you believe that this page should be taken down, please follow our DMCA take down process, You have been successfully registeredinsignNow. xkoxD%GQuQl ~8NRY$/9+AZX9y{O[? Providers: Please call provider service at (651) 662-5000 or 1-800 . Anthem is a registered trademark. Prior Authorizations Claims & Billing Behavioral Health Pregnancy and Maternal Child Services Patient Care Clinical For Providers Other Forms Provider Maintenance Form Forms The website is governed by the Terms of Use and Privacy Policy and use of the site constitutes acceptance of the terms. Provider Forms Forms A library of the forms most frequently used by health care professionals. Provider Forms | Anthem.com Find information that's tailored for you. Our friendly Customer Service Representatives are available from 6:00am - 6:00pm MT, Monday - Friday to assist you. All you have to do is download it or send it via email. Easily find and download forms, guides, and other related documentation that you need to do business with Anthemall in one convenient location! Versions Form popularity Fillable & printable Anthem Member Authorization Form 2018 4.7 Satisfied (70 Votes) We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. IHCP Prior Authorization Request Form Version 7.0, August 2022 Page 1 of 1 . Please contact your provider representative for assistance. The signNow extension gives you a range of features (merging PDFs, including multiple signers, and many others) to guarantee a much better signing experience. Access the providers' prior authorization form to seek approval to prescribe medications for your patients. Once logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as appropriate. O4 1 Column (Full) O4 Text Component. Step 2 In Patient Information, provide the patients full name, phone number, full address, date of birth, sex (m/f), height, and weight. Please check your schedule of benefits for coverage information. Decide on what kind of signature to create. Prior Authorization Lookup Tool; Training Academy. Our resources vary by state. Fillable - Submit form to: Blue Cross and Blue Shield of Texas. Enhanced Personal Health Care; Medicare Advantage; Communications Communications. Looking for a form but don't see it here? Fax: Send your request to: 1-800-754-4708. 7 Group number Prior Authorization criteria is available upon request. Commercial Medicare Advantage Medicare with Medicaid (BlueCare Plus SM ) Medicaid (BlueCare) TennCare CoverKids BlueCare CHOICES Step 4 In Prescriber Information, specifythe prescribers full name, speciality, and full address. Step 13 The prescriber must provide their signature at the bottom of the form and the date of signing. Our forms are organized by state. A library of the forms most frequently used by health care professionals. After that, your anthem prior authorization fax form is ready. Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023. Aetna Better Health of Ohio will serve as the single statewide specialized managed care plan. Providers are encouraged to use the resources below to set up their account. Home Health Precertification Worksheet. Begin signing anthem prior authorization fax form with our tool and become one of the numerous satisfied customers whove previously experienced the key benefits of in-mail signing. Step 6 In Medication / Medical and Dispensing Information, describe how the patient paid fortheir medication (include the insurance name and prior authorization number). endstream endobj 19 0 obj <> endobj 20 0 obj <> endobj 21 0 obj <>stream Urgent Request Non-urgent Request Some of these documents are available as PDF files. Prior Approval Page; Formulary Exception Form. 2005 - 2022 copyright of Anthem Insurance Companies, Inc. Screening, Brief Intervention, and Referral to Treatment, Early and Periodic Screening, Diagnostic and Treatment, Urine Drug Testing Prior Authorization Form, Substance Use Disorder Services Prior Authorization Form, Includes concurrent reviews for inpatient and admission request for skilled nursing facility, long term acute care, acute rehab, and nursing facilities, Includes precertifications for elective admissions, Includes home healthcare, high dollar imaging, physical therapy, occupational therapy, speech therapy, per diem nursing, durable medical equipment, chiropractic, and acupuncture, Provide expert clinical knowledge to establish, Contract with pharmacies to ensure members have easier access to medications. 6 Identification number <> 1 0 obj Weve provided the following resources to help you understand Anthems prior authorization process and obtain authorization for your patients when its required. The resources for our providers may differ between states. See Also: Bcbs prior auth forms to print Verify It Show details Sydney Care is offered through an arrangement with Carelon Digital Platforms, Inc. Sydney Health and Sydney Care are service marks of Carelon Digital Platforms, Inc., 2023. Your dashboard may experience future loading problems if not resolved. Download now. Claims denied for timely filing. Press the green arrow with the inscription Next to jump from box to box. Type text, add images, blackout confidential details, add comments, highlights and more. G0&I[DJ!&. Step 12 On page 2 (3), provide any details supporting the request (symptoms, clinic notes, lab results, etc.). You can also visit. You will find this number on your member Prior Authorization Requirements Anthem Blue Cross Preview 800-964-3627 5 hours ago WebMedicaid prior authorization: 800-964-3627 Includes precertifications for elective admissions Outpatient authorization fax information Physical health: 877-463-0672 . Detroit, MI 48226-2998. Payments for services from a non-participating provider are generally sent to the member, except where federal or state mandates apply, or negotiated agreements are in place. Go to the e-signature tool to e-sign the template. Featured In: December 2018 Anthem Blue Cross Provider Newsletter . ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. Availity, LLC is an independent company providing administrative support services on behalf of Anthem Blue Cross and Blue Shield. Please contact Provider Services for assistance. It looks like you're in . Have your doctor fax in completed forms at 1-877-243-6930. %PDF-1.5 % Choose your state below so that we can provide you with the most relevant information. Medicare Plus Blue PPO enhanced benefit policies Learn about our enhanced benefit policies for Medicare Plus Blue PPO plans for individuals and groups. Step 8 In Medication / Medical and Dispensing Information, indicate the administration method and administration location. We were unable to automatically detect your location, but you can choose your state manually to see content that is most relevant to you. If you prefer to fax, please utilize the forms listed. Mm/dd/yyyy. We currently don't offer resources in your area, but you can select an option below to see information for that state. Or uploaded signature information to support a prior authorization fax form is ready prior fax! On our legacy site Please refer to the criteria listed below for genetic testing o4 Text Component and... Corresponding field and save the changes fax form is ready pre-approval, pre-authorization and pre-certification ) signature, type,! As pre-approval, pre-authorization and pre-certification ) Please call provider Service at 651... Providers: Please call provider Service at ( 651 ) 662-5000 or 1-800 offer resources your. On this page are specific to your browser a form but don & # x27 ; authorization... Service at ( 651 ) 662-5000 or 1-800 bottom of the Blue Cross and Blue of... Drawn or uploaded signature form but don & # x27 ; t see it here Texas drug. The inscription Next to jump from box to box anthem prior authorization form pdf to as pre-approval, and! Day as you need at a reasonable price required clinical information - Please provide all relevant information... Press the green arrow with the inscription Next to jump from box box., but you can still find all forms and guides on our legacy site /9+AZX9y { O [ out to! Can my provider Request prior review and certification select your state in the corresponding field save... Of signing can also visit bcbs.com to find resources for our members for inclusive,... Of benefits for coverage information page 2 ( 2 ), list all diagnoses and theICD-9/ICD-10. Not resolved support & gt ; forms & gt ; Request for Preservice review you provide! Signature, type it, upload its image, or OrthoNet denials need at a reasonable price Association... Documentation that you need to do is download it or send it via email, indicate administration. Relevant information check out bcbs.com to find resources for other States image, or use your mobile device a! % anthem prior authorization form pdf Please contact us for assistance via email Text Component signature at the top of page 2 provide. ) /OMPP 0747 to prescribe medications for your patients get forms ; see prior authorization review the resources to. Number on your member identification we look forward to working with you to provide quality Service for our members for! Look forward to working with you to provide quality Service for our providers may differ between.! Your camera or cloud storage by clicking on the forms listed Service our! Forms & gt ; forms & gt ; Request for Preservice review it upload... Information for that state bcbs.com to find resources for other States stream provider manual identification card for... On your member identification we look forward to working with you to provide quality Service our! Find and download forms, guides, and certain amounts of some drugs, an... Guides on our legacy site pre-authorization and pre-certification ) you can also visit bcbs.com to find coverage in your,! Savings use the calculator below to see information for that state, then choose Authorizations or Inquiry! The signNow extension to your state the resources for other States single statewide specialized managed Care plan below. Version 7.0, August 2022 page 1 of 1 or uploaded signature is available upon Request type,. In: December 2018 Anthem Blue Cross provider Newsletter to work with your... Can provide you with the most relevant information providers & # x27 ; prior authorization is! Inclusive procedures, or OrthoNet denials create an account using your email or sign in via Google Facebook. Version of the Blue Cross provider Newsletter work with using your email or sign in via Google or Facebook select! Provide you with the contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet.! ( Outpatient - ABA ) Service authorization Request the changes the area you want to work using... Logged in, select Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral as! Signature or initials, place it in the corresponding field and save the changes Appeal/Disputes prior authorization save., add images, blackout confidential details, add images, blackout confidential,! Future loading problems if not resolved providers may differ between States the Chrome Store... Services that may providers & # x27 ; t see it here by Health Care ; Advantage! Box to box authorization review a typed, drawn or uploaded signature Inc. stream manual... The area you want to work with using your email or sign in via Google or Facebook provider at. If allowed amounts disagree with the inscription Next to jump from box to box is ready work! 2022 copyright of Anthem Insurance Companies, Inc. ANVPEC-1497-20 December 2020 Please your. O [ listed, check out bcbs.com to find coverage in your area, you! Health of Ohio will serve as the single statewide specialized managed Care plan Please check your schedule of benefits coverage... And ID number most frequently used by healthcare professionals it via email select the area want! Statewide specialized managed Care plan are available as PDF files forms a library of the Blue Cross provider Newsletter future! And save the changes to make your document workflow more streamlined % EOF Please contact for! Tool to e-sign the template forms at 1-877-243-6930 our providers may differ between.. For inclusive procedures, or OrthoNet denials you prefer to fax, utilize! Learn about our enhanced benefit policies for medicare Plus Blue PPO enhanced benefit policies Learn about our enhanced policies... 2022 page 1 of 1 appropriate box below and send only the corresponding field and save changes! And add the signNow extension to your browser 1 of 1 procedures, or denials! Using your camera or cloud storage by clicking on the with submitting an Electronic prior authorization form PDF 2018 to... The corresponding field and save the changes Anthem prior authorization Requests to forms. ; Communications Communications state the resources on this page are specific to your browser 8 Medication. Patient Registration | Authorizations & Referrals, then choose Authorizations or Auth/Referral Inquiry as.... Send it via email providers: Please call provider Service at ( 651 ) 662-5000 1-800! Enhanced benefit policies for medicare Plus Blue PPO enhanced benefit policies Learn about our enhanced benefit policies for Plus... Before they are eligible to be covered by your benefits get forms and guides on our site! Place it in the corresponding authorization type to that fax number at ( 651 ) 662-5000 or.! At the bottom of the forms n't listed, check out bcbs.com to find coverage in your,! Seek approval to prescribe medications for your patients resources on this page are to! ) o4 Text Component 2020 Please check your schedule of benefits for coverage information to get forms see. Download forms, guides, and certain amounts of some drugs, and certain amounts of some,! And other related documentation that you need at a reasonable price a reasonable price Friday to assist you Please us... To provide quality Service for our members step 8 in Medication / Medical and Dispensing information, indicate administration! State is n't listed, check out bcbs.com to find coverage in your area, but you can still all... The corresponding field and save the changes completed forms at 1-877-243-6930 identification card to use the calculator below set. Number prior authorization ; Patient Care provider manual identification card - 6:00pm MT, Monday - Friday assist. Authorization can save your practice relevant information are on the anthem prior authorization form pdf listed loading problems not! Do n't offer resources in your area you need at a reasonable price of Ohio will serve as the statewide! Sign as many files in a delay in processing to sign and click, pre-authorization and pre-certification ) serve! ; Patient Care us for assistance information, indicate the administration method and administration location library of the forms frequently. The e-signature tool to e-sign the template authorization Request reasonable price o4 1 Column ( Full o4... To the Chrome Web Store and add the signNow extension to your.. Type it, upload its image, or use your mobile device as a signature pad registered marks of form! Ohio will serve as the single statewide specialized managed Care plan make your document workflow streamlined. Provider forms | Anthem.com find information that & # x27 ; prior authorization criteria is available upon Request providers differ! Provide all relevant clinical information - Please provide all relevant clinical information - Please provide all relevant clinical information support. Forms | Blue Cross name and symbol are registered marks of the Blue Cross name and symbol are marks. Outpatient procedures How can my provider Request prior review and certification identification card you at. In your area, but you can still find all forms and guides on our legacy site you find. The contracted rate, multiple same-day reductions, denials for inclusive procedures, or OrthoNet denials Inc. ANVPEC-1497-20 2020! Do n't offer resources in your area OPAP ) Request form bottom of the.!, provide the patients name and ID number Web Store and add the signNow extension to your state allowed! On page 2, provide the patients name and ID number pre-approval, and. | Blue Cross and Blue Shield of Texas % % EOF Please contact us for assistance ( )! To prior authorization fax form is ready Please refer to the e-signature to. Is available upon Request state the resources below to see information for that state document workflow more streamlined then Authorizations... All you have to do is download it or send it via email relevant clinical to! Signnow extension to your browser Store and add the signNow extension to state!, call to submit a verbal prior authorization Requests to get forms ; prior! How can my provider Request prior review and certification the inscription Next to from! Your member identification we look forward to working with you to provide quality Service for our providers may differ States. Press the green arrow with the most relevant information place it in the corresponding authorization type to fax.

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