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Get USScript Prior Authorization Request Form

Ber name, ID#, and drug name. Incomplete forms will delay processing. A 72-hour supply of medication may be requested by phoning 1-800-460-8988. US Script will respond via fax or phone within 24 hours of receipt of all necessary information, except during weekends and holidays. For immediate response on weekends and holidays, NurseWise will answer your call. I. Provider Information II. Member Information Prescriber name (print): Member Name: Office Contact Name: ID#: Fax: Date of Birth: .

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