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-298-8700 CHECK ALL BOXES THAT APPLY Prior Authorization and Appeals Support Patient Assistance Program (PAP) Eligibility Screening GILEAD MEDICATION REQUESTED (REQUIRED) 2 Product Name: mg: PRESCRIBER INFORMATION (REQUIRED) 3 Prescriber Name: Facility Name: Address: City: State: Office Contact: Zip Code: Phone #: NPI #: Fax #: Tax ID #: State License #: 4 DIAGNOSIS / MEDICAL INFORMATION (REQUIRED) MUST BE COMPLETED BY HEALTHCARE PROVIDER Diagnosis (Please include ICD-9 co.

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