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Get Special Authority

Consult a pharmacist concerning the Special Authority process. I have discussed with the patient the purpose of the release of the patient s information to PharmaCare to obtain Special Authority for prescription benefit and for the purposes set out above. Presciber s Signature (Mandatory) Patient Signature (Optional) PharmaCare may request additional documentation to support this Special Authority request. pharmacare use only effective date YYYY / MM / DD Duration of therapy / termina.

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