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01/18/2016 Prior Authorization MERCY MARICOPA INTEGRATED CARE - TXIX/XXI SMI MEDICAID AZ88 This fax machine is located in a secure location as required by HIPAA regulations. Of or a tricyclic antidepressant i.e. or at a maximum tolerated dose If yes list medication s tried and reason for failure associated with diabetes OR spinal cord injury OR cancer of at least 1 formulary agent OTHER than such as topical capsaicin tricyclic antidepressants or 7. Complete/review information sign and date....
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