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Get Amidacare Prior Authorization Form - And 2014-2024

Name: Prescriber Name: Patient Last Name: Prescriber DEA/NPI (required): Prescriber Phone #: Patient ID#: Prescriber Patient DOB: Fax #: Prescriber Address: Patient Phone #: _ Primary Diagnosis: State: Zip Code: ICD Code: Please indicate which drug and strength is being requested: â–¡ â–¡ â–¡ 50mg Tablet 150mg Tablet 250mg Tablet â–¡ â–¡ 100mg Tablet 200mg Tablet Directions for use (i.e. QD, BID, PRN & Qty): Please complete the clinic.

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