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Tain requests for coverage require review with the prescribing physician. Please answer the following questions and fax this form to the number listed above. Please note any information left blank or illegible may delay the review process. Patient Name:NA Prescriber Name:NA Member Number: Fax: Date of Birth: Office Contact: Group Number: NPI: Address: Address: City, State, Zip: City, State, Zip: Phone: State Lic ID: Member Phone: rExpedited/Urgent Drug Name: Directions: Please a.

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