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What is the patient s HCV genotype C. Will both and be used in combination with Sovaldi Yes No Patient is intolerant to or has contraindication D. Sovaldi Reset Form sofosbuvir Member Last Name ID Primary Care Physician First Name DOB Gender Requesting Provider Provider Address Provider NPI Prov. Phone Prov. Fax Contact Name What is the provider s specialty Provider Signature Gastroenterologist Hepatologist Infectious disease specialist Other Date Product Information Drug product Sovaldi...
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