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T programs (OTPs) under 42 CFR 8.11(h). Detailed INSTRUCTIONS are on the cover page of this form. PLEASE complete ALL applicable items on this form. Your cooperation will result in a speedy reply. Thank you. Program OTP No: - BACKGROUND INFORMATION (e.g., AL-10001-M) - Patient ID No: Program Name: Telephone: Fax: E-mail: Name & Title of Requestor: Patient s Admission Date: Patient s current dosage level: Patient s program attendance schedule per week S (Place an.

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