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Get ® () Injectable Medication Precertification Request

Re Request Form Page 1 of 3 (All fields must be completed and legible for precertification review.) Please indicate: Start of treatment: Start date / Continuation of therapy: Date of last treatment / Precertification Requested By: Phone: / / Fax: A. PATIENT INFORMATION First Name: Last Name: DOB: Address: Home Phone: Work Phone: Patient Current Weight: lbs or kgs Patient Height: City: State: Cell Phone: E-mail: inches or ZIP: cms Allergies: B. INSURANCE INFORMATION Aet.

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