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Yes Are the following tests being performed prior to initiation of 1. A recent CBC i.e. within the last 6 months 2. Com Member s Last Name Member s First Name SCAN ID number Date of Birth Prescriber s Name Contact Person Office phone Office Fax Medication Diagnosis SECTION A Yes No Please answer the following questions Is the diagnosis or indication for the treatment of patients with relapsing forms of Multiple Sclerosis to reduce the frequency of clinical exacerbations and to delay the...
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