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Member ID# Date Submitted Name DEA#(including X) Phone NPI # DX DOB Prescriber Name Fax Diagnosis Phone SPECIALTY Alternate Phone Contact Form must be completed, signed and submitted by a physician
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What is 33ekyparequestformsuboxone?
33ekyparequestformsuboxone is a specific form used for requesting suboxone medication.
Who is required to file 33ekyparequestformsuboxone?
Medical practitioners who prescribe or administer suboxone medication are required to file 33ekyparequestformsuboxone.
How to fill out 33ekyparequestformsuboxone?
To fill out 33ekyparequestformsuboxone, you need to provide the required information such as patient details, medical history, dosage instructions, and any relevant supporting documentation.
What is the purpose of 33ekyparequestformsuboxone?
The purpose of 33ekyparequestformsuboxone is to ensure proper documentation and authorization for prescribing or administering suboxone medication.
What information must be reported on 33ekyparequestformsuboxone?
33ekyparequestformsuboxone requires reporting of patient information, medical history, prescribed dosage, healthcare provider details, and other relevant information.
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