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Below this letter outlines insert patient name s medical history prognosis and treatment rationale. Please call my office at insert telephone number if I can provide you with any additional information. I look forward to receiving your timely response and approval of this claim. Sincerely Insert Doctor name and participating provider number Enclosures RADICAVA is a trademark of Mitsubishi Tanabe Pharma Corporation. 2017 MT Pharma America Inc. All rights reserved. US only....
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