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5mg/dl Please provide medical record documentation. Specify corrected serum calcium level Date s one intravenous bisphosphonate e.g. acid acid Please provide medical record documentation. ONLY SIGNED AND COMPLETED FORMS CAN BE PROCESSED Member/Provider Information HPHC Member s Name HPHC Member s HPHC ID Provider s Name 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...
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