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Name: Fillable Online IF YOU ARE NOT THE PATIENT OR THE PRESCRIBER, YOU WILL NEED TO SUBMIT A PHI DISCLOSURE AUTHORIZATION FORM WITH THIS REQUEST WHICH CAN BE FOUND AT THE Fax Email Print - pdfFiller
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Rebels (Semaglutide) Prior Authorization Request Form Caterpillar Prescription Drug Benefit Phone: 8772287909 Fax: 8004247640 Instructions: Please fill out all applicable sections completely and legibly.

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