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Gov. WEBPBSC-0366-17 February 2017 SC Medicaid PAB Fax Form 01. 17. 17. docx All requests Patient has hypercalcemia defined as a serum corrected total calcium level of greater than 10. 9. PHYSICIAN SIGNATURE Prescriber or authorized signature Date treating physician can determine what medications are appropriate for a patient. Requests for injection Patient has a diagnosis of Stage 5 chronic kidney disease requiring dialysis. APPROVAL CRITERIA CHECK ALL BOXES THAT APPLY NOTE Any areas not...
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