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04/03/2016 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID Caprelsa AZ88 This fax machine is located in a secure location as required by HIPAA regulations. Is the patient responding to therapy No further questions 3. Does the patient have a diagnosis of locally recurrent or metastatic differentiated thyroid carcinoma including papillary follicular and Hurthle cell 4. Complete/review information sign and date. Fax signed forms to Mercy Maricopa Integrated Care -...
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