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Get and Sign Manulife Gl3803b Form

Get and Sign Manulife Gl3803b Form

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Dosage and Quantity (requested for reimbursement) Specific Clinical and Diagnostic Evidence Supporting the use of this Medication Identify reason why this drug product is now prescribed: e.g., patient's history, risk factors, concurrent use of other drugs (list drugs) failure to respond to or experienced adverse reactions to other drugs. Identify other drugs prescribed currently or previously for claimants condition (as identified above) Expected Duration of Therapy: For non-orally...
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