Get the free Nicotine Replacement Therapy Fax Form - Maryland DHMH - dhmh maryland
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Maryland Medicaid Pharmacy Program Fax: (866) 4409345 Phone: (800) 9323918 Nicotine Replacement Therapy (NRT) Prior Authorization Form Patients Information: DATE: NAME: DOB: Recipients Maryland Medicaid
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What is nicotine replacement therapy fax?
Nicotine replacement therapy fax is a document used to request authorization for nicotine replacement therapy products.
Who is required to file nicotine replacement therapy fax?
Healthcare providers are required to file nicotine replacement therapy fax on behalf of their patients.
How to fill out nicotine replacement therapy fax?
To fill out nicotine replacement therapy fax, healthcare providers must include patient information, medical history, and reason for requesting nicotine replacement therapy.
What is the purpose of nicotine replacement therapy fax?
The purpose of nicotine replacement therapy fax is to obtain authorization for nicotine replacement therapy products for patients trying to quit smoking.
What information must be reported on nicotine replacement therapy fax?
Nicotine replacement therapy fax must include patient demographics, medical history, current smoking habits, and rationale for requesting nicotine replacement therapy.
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