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Which are also operating subsidiaries of CIGNA Corporation. AFDDS Electronic Form - TD10 Rev. 5-05. Clear Fields CIGNA Tel-Drug Specialty Pharmacy Fax Order Form R Please deliver by Requests received after 4 p.m. CST will begin processing the following business day. PATIENT INFORMATION Please Print PATIENT NAME CIGNA HEALTHCARE ID Fax 1. 800. 351. 3616 Phone 1. 800. 351. 3606 Referral Source Code Order PHYSICIAN INFORMATION NAME DAT.

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