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Acaria Health Pulmonary Arterial Hypertenstion Referral Form Pulmonary Arterial Hypertenstion Referral Form
Emergency Contact Please attach demographic information PRESCRIBER INFORMATION Prescriber NPI DEA State Lic Supervising Physician Practice Name Fax Key Office Contact DIAGNOSIS INFORMATION / MEDICAL ASSESMENT Primary Diagnosis ICD-10 Code Description Has patient been treated previously for this condition Yes No Medication s Is patient currently on therapy Yes No Medication s Will patient stop taking the above medication s before starting the new medication Yes No If yes How long should patient...
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