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888-836-0730. When conditions are met, we will authorize the coverage of . Drug Name (select from list of drugs shown) ( cypionate) Patient Information Patient Name: Patient ID: Patient Group No.: Patient DOB: Patient Phone: Prescribing Physician Physician Name: Physician Phone: Physician Fax: Physician Address: City, State, Zip: Diagnosis: ICD Code: Please circle the appropriate answer for each question. 1. Is the patient male? Y N [If the an.

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