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Get New Hampshire Medicaid Fee-for-service Program Prior Authorization

TION AND MEDICATION REQUESTED Patient s Name Medicaid Number Date of Birth (MM/DD/YYYY) / / Gender Male Female Drug Name Strength Dosing Schedule Length of Therapy Number of Injections Needed HCPC Code (for KePRO Only) SECTION II: CLINICAL HISTORY 1. Patient s diagnosis for use of this medication (please be complete and use a separate sheet if additional space is required): 2. Previous failure, contraindication, or adverse reaction to AND at least one DMARD (sul.

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