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Aetna Better Health of Louisiana Pharmacy Prior Authorization Request Form Directing Antiviral (DAA) Agents Used to Treat Chronic Hepatitis C Virus (CV) Fax back to 18446992889Note: This worksheet
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Individuals who are seeking treatment or medications for Hepatitis C, and are required to submit a formal request for DAA (Direct-Acting Antivirals) can make use of the abh-la-hepatitis-c-daa-request-form-071519 accessible pdf.
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The ABH-LA Hepatitis C DAA Request Form is a document used to request authorization for direct-acting antiviral (DAA) treatments for hepatitis C. The 'accessible PDF' version is designed to be easily readable and usable by individuals with disabilities.
Healthcare providers or authorized representatives who are requesting DAA treatments for patients diagnosed with hepatitis C are required to file the form.
To fill out the form, complete each required section with accurate patient information, treatment details, and any necessary supporting documentation. Ensure that the form is signed by the healthcare provider before submission.
The purpose of the form is to facilitate the process of obtaining authorization for hepatitis C DAA treatments, ensuring that patients receive the necessary medical interventions.
The form requires the patient's demographic information, details about the hepatitis C diagnosis, prescribed DAA medications, and any relevant clinical information or previous treatment history.
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