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I attest that the information provided on this form is true and accurate as of this date Prescriber s signature Date. To process this request documentation that all formulary alternatives would not be as effective or would have adverse effects is required. Please provide clinical information or other evidence supporting the medical necessity of the nonformulary drug including previous formulary drugs attempted for this patient s condition. If the formulary exception is approved it will be...

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How to fill out fax completed form to

1. Step 1: Gather all the necessary information and documents that need to be included in the fax completed form.
2. Step 2: Make sure you have a working fax machine or an electronic fax service.
3. Step 3: Open the fax completed form and start filling it out.
4. Step 4: Provide accurate and complete information in each section of the form.
5. Step 5: Double-check all the filled-out fields for any errors or omissions.
6. Step 6: Attach any supporting documents if required.
7. Step 7: Review the completed form once again to ensure everything is in order.
8. Step 8: Input the recipient's fax number correctly in the designated field.
9. Step 9: Send the faxed completed form by either using the fax machine or the electronic fax service.
10. Step 10: Confirm the successful transmission of the fax by checking for a fax confirmation receipt or notification.

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Details such as name, contact information, identification number, and any other required data.