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BUPRENORPHINE AND BUPRENORPHINE/NALOXONE PRIOR AUTHORIZATION REQUEST From This form is for authorization of prescription drug benefits only and must be COMPLETELY filled out. GENERAL INFORMATION Patient Name Patients Home

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What is this form is for?

This form is used for reporting income and expenses for tax purposes.

Who is required to file this form is for?

Individuals and businesses who have income and expenses that need to be reported to the tax authorities.

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The form can be filled out manually or electronically, with all relevant information accurately provided.

What is the purpose of this form is for?

The purpose of the form is to ensure that income and expenses are accurately reported and taxes are paid accordingly.

What information must be reported on this form is for?

Income, expenses, deductions, and credits must be reported on this form.

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