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Get Regal Medical Group Prior Authorization Form

Y Case Management Medical Director. Chronic Medical Conditions Asthma Depression Dementia CHF COPD Diabetes HTN PVD CAD ESRD Obesity CKD Past Surgical History Wound Problem : Cancer: : CVA hx : AIDS/HIV Anticoagulation Others: High Risk Criteria Poor Social Support: Poor Functional Status: Poor Nutritional Status: Medications 1) 4) 7) 10) 13) Psychological Condition: Substance Abuse, Tob, Etoh, non-compliance:.

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  • COPD
  • CVA
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  • nutritional
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