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PRIOR AUTHORIZATION REQUEST PATIENT:Name Address: City, State, Zip D.O.B. Member ID:Prescriber:_Medication Requested: IsotretinoinName Address City, State, Zip Phone Fax NPIQty Requested:Your patients
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Additional quantities refer to the extra amounts of products or services that a business may report or track for purposes such as inventory management, compliance, or regulatory requirements.
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Information that must be reported includes item descriptions, quantities on hand, quantities ordered, and any relevant data regarding inventory management practices.
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