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Audit Date Med D Claim Type (check one) Prescription Number Date(s) of Fill Reason for Dispute TRICARE Other Discrepancy Code(s) Please provide a clear and concise explanation of grievance and include evidentiary documentation which would support a reversal of ESI's final audit findings. Accepted documentation: a. Photocopy of the original prescriber-generated prescription (front and back), which must be dated and if a fax, must have a header identifying the prescriber and the original fax.

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