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Drug Name please circle CR Intermezzo Other please specify Quantity Route of Administration Frequency Expected Length of therapy Strength Patient Information Patient Name Patient ID Patient Group No. Patient Phone Prescribing Physician Physician Name Specialty NPI Number Physician Fax Physician Phone Physician Address City State Zip Diagnosis ICD Code Please circle the appropriate answer for each question. Question 1. Has the patient had a documented one month treatment failure claims history...
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