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PRIOR AUTHORIZATION PROGRAM REIMBURSEMENT REQUEST FORM For muscle or nerve disorders: (onabotulinumtoxinA)Please fax form to: 18668401509Please note that the patient AND physician must complete this
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What is selected muscle or nerve?
Selected muscle or nerve refers to the specific muscle or nerve that is being targeted or focused on in a medical examination or treatment plan.
Who is required to file selected muscle or nerve?
Healthcare professionals, such as doctors or physical therapists, are typically required to file information regarding the selected muscle or nerve.
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The selected muscle or nerve can be filled out by providing detailed information on the location, function, and any relevant conditions or injuries affecting it.
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The purpose of focusing on a selected muscle or nerve is to assess its health, diagnose any issues, and prescribe appropriate treatments or exercises.
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Information such as symptoms, medical history, diagnostic tests, and treatment plans related to the selected muscle or nerve must be reported.
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