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Get Aetna GR-68285 Form 2011

F 2 Please return both pages for precertification of medications. Please note that authorizations are valid for one cycle only and a request form must be submitted for each cycle. Please indicate: Ship to: Start of treatment Doctor s office Dispensing Provider: Today s date: Continuation of therapy, date of last treatment cycle Patient Date needed: Other: Aetna Specialty Pharmacy Phone: or Other: Phone: Fax: TIN: Precertification Requested By: A. PATIENT INFORMATION PIN:.

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