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D. /D. O. Office Contact Name / Fax attention to Section C - Medical Information Medication Strength Dispense as Written Yes No Directions for use Quantity Diagnosis Please be specific provide as much information as possible ICD-10 CODE Is this member pregnant Yes No If yes what is this member s due date Section C Previous Medication Trials Section D Previous Medication Trials Directions Dates of Therapy Reason for failure / discontinuation Section E Additional information about this case if...

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How to fill out this form contains multiple

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This form contains multiple is a document that allows for the reporting of multiple entries or items.

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Any individual, business, or organization that needs to report multiple entries or items is required to file this form.

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Information such as names, amounts, descriptions, and any other relevant details for each entry or item must be reported.