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State of Maine Department of Health & Human Services Maintain/MODEL Prior Authorization Form BOTULINUM Phone: 18884450497www.mainecarepdl.organ: 18888796938Requesting prescriber (if not a neurologist,
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Pharmacy-fax to 1-888-879-6938or is a form used for submitting pharmacy information via fax.
All pharmacies are required to file pharmacy-fax to 1-888-879-6938or.
You can fill out pharmacy-fax to 1-888-879-6938or by providing all the necessary pharmacy information requested on the form.
The purpose of pharmacy-fax to 1-888-879-6938or is to report pharmacy information to the specified fax number.
The information that must be reported on pharmacy-fax to 1-888-879-6938or includes pharmacy name, address, contact information, and any other requested details.
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