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Get and Sign Symphonix Health Insurance Inc 2012 Form

Get and Sign Symphonix Health Insurance Inc 2012 Form

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Use: Date Started: Diagnosis: Name of Specific Medications Tried and Failed: Reason for Non-Formulary Request. (Patient chart notes will be requested if further documentation is necessary): Additional Notes: Physician Signature: Date: Prescriber - return COMPLETED and SIGNED form to: OptumRx Prior Authorization Dept. CA106-0286 3515 Harbor Blvd Costa Mesa, CA 92626 Phone: 1-800-711-4555 Fax: 1-800-527-0531 Please contact us by telephone for urgent/ expedited requests You may also...
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