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Fax completed prior authorization request form to 8008547614 or submit Electronic Prior Authorization through CoverMyMeds or Subscripts. All requested data must be provided. Incomplete forms or forms
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It is a form used to request monoamine depletors accessible in PDF format.
Healthcare providers and facilities who need to administer monoamine depletors.
The form should be completed with the required information such as patient details, medical history, and requested dosage.
The purpose is to ensure proper documentation and authorization for the use of monoamine depletors.
Patient information, medical history, dosage requirements, and prescribing physician details.
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