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UNIFORM PHARMACY PRIOR AUTHORIZATION REQUEST FORM CONTAINS CONFIDENTIAL PATIENT INFORMATION Complete this form in its entirety and send to Rocky Mountain Health Plans at 8583572538 Urgent 1 Monument
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What is requested drug name?
The requested drug name is the name of the medication that is being sought for filing or reporting purposes.
Who is required to file requested drug name?
The individual or entity responsible for the medication, such as the manufacturer or distributor, is required to file the requested drug name.
How to fill out requested drug name?
The requested drug name can be filled out by providing the accurate name of the medication as it appears on the packaging or labeling.
What is the purpose of requested drug name?
The purpose of the requested drug name is to properly identify the medication being filed or reported.
What information must be reported on requested drug name?
The requested drug name must include the brand name, generic name, and any additional identifying information about the medication.
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