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Get Oh Medco-31 2013

Presentative, please call 877-615-6330. Injured worker information Request date BWC claim number Injured worker name Injured worker date of injury Prescriber information Prescriber Prescriber NPI Prescriber phone Prescriber fax number Medication requested and conditions being treated (Required) Medication name ICD-9 code(s) ICD-9 code description(s) 1. 2. 3. 4. Non-sterile compound Sterile compound (pain pump)    Brand name drug: The injured worker has a documented, systemi.

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