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Description of restat prior authorization form
Date PRIOR AUTHORIZATION FORM M. D. Last Name Physician Phone M. D. First Name Physician Fax Patient ID DOB TO ENSURE PROMPT PROCESSING PLEASE COMPLETE ALL OF THE QUESTIONS. Complete the following for the drug requested Drug name Strength SIG Length of Therapy Disease State Diagnosis Code Chart notes are required to document failure from the physician in order to override the benefit. Treatment / Drug Used Date s...
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