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(beta1a) Prescription and Service Request Form Fax this form to: 18662273243 Call us toll-free: 18774473243 Physician ID# STEP 1: Complete Physician Information STEP 2: Complete Patient Information

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1. Gather all necessary information and documents required to fill out the beta-1a - accredo form, such as personal details, medical history, and insurance information.
2. Start by entering your personal information accurately, including your full name, date of birth, contact information, and address.
3. Provide your insurance details, including your insurance provider's name, policy number, and any other relevant information required by the form.
4. Fill out the medical history section, providing details about your previous diagnoses, treatments, medications, and any other relevant information related to your condition.
5. If applicable, provide information about the prescribing physician, including their name, contact details, and any relevant notes or instructions provided by them.
6. Double-check all the information entered in the form to ensure accuracy and completeness.
7. Sign and date the form, as required, to certify that the information provided is true and accurate.

Who needs beta-1a - accredo:

1. Patients diagnosed with relapsing forms of multiple sclerosis (MS) may require beta-1a - accredo medication as part of their treatment plan.
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What is beta-1a - accredo?

Beta-1a - accredo is a medication used to treat multiple sclerosis.

Who is required to file beta-1a - accredo?

Healthcare providers and pharmacies are required to file beta-1a - accredo.

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Beta-1a - accredo can be filled out by following the instructions provided by the manufacturer or healthcare provider.

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Information such as patient name, prescription details, dosage instructions, and healthcare provider information must be reported on beta-1a - accredo.