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If you are not the intended recipient please notify the sender immediately. Office use only OtezlaCMS2016May-W.doc Check all that apply Concurrently Taking Tried/ Contraindication/ Failed Intolerance NSAIDs e.g. ibuprofen naproxen 6- Corticosteroids e.g. 6- Immunosuppressant TNF-alpha blocker Please document dates of therapies for medications selected Reauthorization Does the patient have documentation of positive clinical response to medication therapy Yes No Are there any other comments...
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To fill out an office street address, follow these steps:
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Start by writing the building number or name of the office on the first line.
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If applicable, include additional information such as the floor number, suite number, or office name on the third line.
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On the fourth line, write the name of the city or town where the office is situated.
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