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Get WellCare GA020239 PRO FRM ENG 2012-2024

Physician with a Drug Addiction Treatment Act (DATA) waiver** (UIN #) Drug Requested: [ ] ® SL Film Tab 8mg/2mg [ ] ® SL Film Tab 2mg/0.5mg [ ] SL Tab 8mg [ ] SL Tab 2mg Quantity: ____________ Sig: ________________________________ Start date of this PA: ______________ **Doses above 32 mg per day will NOT be approved. 1. Primary Diagnosis: ICD-9: _______________________________________________________ 2. Psychosocial Counseling: ______________.

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