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Get Phone: 1-844-468-2252 Fax: 1-844-237-3172

Pharmacy: If the product will be ordered through a specialty pharmacy for administration in the provider s office, please choose this option. If requesting that the prescription referral be triaged to a specialty pharmacy, check the Specialty Pharmacy Triage service at the top of the form. Additionally, the provider will need to complete two additional sections: 1) Prescription Referral Information, and 2) Diagnosis and Clinical Information. IMPORTANT: Once Gateway to has triaged.

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