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Prescribing Clinician or Authorized Representative Signature Date Created 07/16 Reviewed/Revised 01/24/2017 3/28/2017 11 30 AM. ONLY COMPLETED FORMS CAN BE PROCESSED Member/Provider Information HPHC Member s Name Provider s Name HPHC Member s HPHC ID Provider s Specialty Pharmacy used by HPHC Member DEA HPHC-Affiliated Physician YES Provider s Telephone Number/Contact Name Pharmacy Area Code Telephone Number Provider s Area Code Fax Number HPHC Member s DOB mm-dd-yy NO Clinical Information...
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