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Nevada MedicaidrexSubmit fax request to: 8554553303 Please note: All information below is required to process this request. Hematopoietic/Heating Agents Prior Authorization Request Form DO NOT COPY
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It is important to consult with a healthcare provider to determine if hematopoietichematinic agents are appropriate and necessary for your specific condition.
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Hematopoieticchelatinic agents are medications that stimulate the production of blood cells.
Healthcare providers and pharmacies may be required to report the use of hematopoieticchelatinic agents to regulatory authorities.
Hematopoieticchelatinic agents can be filled out by documenting the dosage, frequency, and duration of treatment for each patient.
The purpose of hematopoieticchelatinic agents is to treat conditions such as anemia or low blood cell counts.
Information that must be reported may include patient name, date of birth, medical history, and any adverse reactions to the medication.
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