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Get OH MEDCO-31 2016-2024

Epresentative, call 877-543-6446. Injured worker information Request date BWC claim number Injured worker name Injured worker date of injury Prescriber information Prescriber Prescriber NPI Prescriber phone Prescriber fax number Medication requested and conditions being treated (Required) Medication name ICD code(s) ICD code description(s) 1. 2. 3. 4. Non-sterile compound Sterile compound pain pump    Sterile compound other    Brand name drug: The injured .

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