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Get CO Prior Authorization Form 2017-2024

MATION LAST NAME: FIRST NAME: STREET ADDRESS: STATE: CITY: PHONE NUMBER: ZIP: FAX NUMBER: NPI NUMBER: DEA NUMBER: DRUG INFORMATION DRUG REQUESTED: STRENGTH: QUANTITY: FREQUENCY OF DOSING: DIAGNOSIS: METHOD OF DIAGNOSIS (IF APPLICABLE): FAILED MEDICATIONS: CONTRAINDICATIONS/ALLERGIES: CURRENT MEDICATIONS: RELEVANT LAB VALUES: DATE OF LAB RESULTS: MEDICAL JUSTIFICATION: WHERE WILL MEDICATION BE ADMINISTERED? (CHECK ONE): Client s Home Long-Term Care Facili.

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