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Get Fax Completed Form To 18003579577

Information beyond what is specifically requested. Fax completed form to 1-800-357-9577 If this an URGENT request, please call 1-800-417-8164 Additional forms available: www.express-scripts.com/pa Patient Information Prescriber Information Patient First Name: Prescriber Name: Patient Last Name: Prescriber DEA/NPI (required): Prescriber Phone #:.

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