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This authorization expires when a Pharmion determines I am not eligible to participate in the Patient Assistance Program or b my participation in the Patient Assistance Program ends whichever is earlier. I understand that I have the right to revoke this authorization at any time by providing written notice to Pharmion Corporation. Patient s Original Signature Date // Prescribing Physician Information Section 4 Completed by physician Physician Na.

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Keywords relevant to Patient Assistance Programs Form

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  • ICD-9
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  • prepayment
  • ELIGIBILITY
  • YR
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  • dispensing
  • Advocacy
  • annuity
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