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Prescribing Clinician or Authorized Representative Signature Created 10/11/2016 Reviewed/Revised 01/24/2017 Date 3/28/2017 11 29 AM. Tuzistra XR chlorpheniramine/codeine Medication Request Form MRF FAX TO 888 807-6643 c/o MedImpact Healthcare Systems Inc. Attn Prior Authorization Department 10181 Scripps Gateway Court San Diego CA 92131 - Phone 1-800-788-2949 Instructions This form is to be used by participating providers to obtain coverage for the drug listed above which require prior...
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