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Express scripts form Express-scripts. com/pa Fax completed form to 1-800-357-9577 If this an URGENT request please call 1-800-417-8164 Patient Information Prescriber Information Patient First Name Prescriber Name Patient Last Name Prescriber DEA/NPI required Patient ID Prescriber Phone Prescriber Fax Patient Phone Prescriber Address State Zip Code Primary Diagnosis ICD Code Please indicate which drug and strength is being requested 2. 5mg/24hr Transdermal System 1 Metered Dose Pump Transdermal Gel 1. 62 Metered Dose Pump Transdermal Gel 1 Transdermal Gel 30mg/actuation Topical Solution First- 2 Compounding Kit 10mg/actuation Transdermal Gel 30mg Buccal System 1 Topical Gel Other Directions for use i.e. QD BID PRN Qty Please complete the clinical assessment 1. Prior Authorization Form Topical This form is based on Express Scripts standard criteria and may not be applicable to all patients certain plans and situations may require additional information beyond what is specifically requested* Additional forms available www. express-scripts. com/pa Fax completed form to 1-800-357-9577 If this an URGENT request please call 1-800-417-8164 Patient Information Prescriber Information Patient First Name Prescriber Name Patient Last Name Prescriber DEA/NPI required Patient ID Prescriber Phone Prescriber Fax Patient Phone Prescriber Address State Zip Code Primary Diagnosis ICD Code Please indicate which drug and strength is being requested 2. 5mg/24hr Transdermal System 1 Metered Dose Pump Transdermal Gel 1. 62 Metered Dose Pump Transdermal Gel 1 Transdermal Gel 30mg/actuation Topical Solution First- 2 Compounding Kit 10mg/actuation Transdermal Gel 30mg Buccal System 1 Topical Gel Other Directions for use i*e* QD BID PRN Qty Please complete the clinical assessment 1. Does the patient have hypogonadism primary or secondary as confirmed by a low for age pre-treatment serum total or free level defined by the normal laboratory reference values Yes No N/A 2. Is the requested medication going to be used to enhance athletic performance endocrinologist the prostate 5. Is the patient 14 years of age or older AND the medication is being requested for the treatment of delayed puberty or induction of puberty 8. 27. 2013 7. Has the patient tried any of the following medications Are there any other comments diagnoses symptoms and/or any other information the physician feels is important to this review Prescriber Signature Date Office Contact Name Phone Number Based upon each patient s prescription plan additional questions may be required to complete the prior authorization process. If you have any questions about the process or required information please contact our prior authorization team at the number listed on the top of this form* physician* Only a treating physician can determine what medications are appropriate for the patient.

Logger safety checklist bookle... Logger Safety Checklist Booklet Revised 2006 The North Carolina Forestry Association (NCFA) is a private, nonprofit association of loggers, landowners, forest managers and forest products companies.

Order form jacket 30 business days 2 week rush 100 per jacket s/h PLEASE FAX THE COMPLETED FORM TO 1-866-224-7335 OR EMAIL IT TO CUSTOMERSERVICE S4G.COM. IF YOU NEED ASSISTANCE PLEASE CALL 1-866-22-GREEK. I the undersigned authorize these charges and fully agree to the Terms and Conditions stated at stuff4greeks. com. Sign your name or type your initials here. cardholder s signature SAVE PRINT SUBMIT BY EMAIL If this is a group order complete page 2 before you submit. crossing jacket RIGHT SLEEVE stuff4GREEKS*com the paraphernalia of choice lowercase UPPERCASE 1. Click on the picture and type or describe what you want in each area* Use UPPERCASE for Greek letters lowercase for regular letters. TM a b c d e f g h i j k l m n o p q rst u v wx y z A B C D EF G H I J K L M N OPQ RS T UV W X YZ COLLAR 2. Complete the billing form* 3. For group orders also complete page 2. 4. Submit by email or fax. BACK FRONT switch positions of letters and crest LEFT SLEEVE product info sizing chart S 34-36 M 38-40 L 42-44 XL 46-48 2XL 50-52 3XL 54-56 4XL 58-60 5XL 62-64 6XL 66-68 choose a package for double lettering only See stuff4greeks. com/crossingjackets for details. basic standard deluxe ultimate OR check the features you want us to add to your jacket Use the options below if you are sending us a jacket or if you want to add more features that aren t included with your package. available options base price/blank jacket large greek letters on front words through letters half-and-half letters super 3D letters triple-layered letters shield/crest monograms text on right sleeve text on left sleeve sleeve icon on right sleeve sleeve icon on left sleeve text on collar line name on back name of line on back artwork on back icons along bottom back only icons around entire bottom jacket color see colors at stuff4greeks. com/charts jacket size brand optional letter color letter outline color price 10 each customer info name phone email credit card info credit card number expiration date / verification code name on card if different from above billing address for this credit card street apt city state zip ship to address if different from billing address estimated total turnaround time shipping normal production approx. 30 business days 2 week rush 100 per jacket s/h PLEASE FAX THE COMPLETED FORM TO 1-866-224-7335 OR EMAIL IT TO CUSTOMERSERVICE S4G*COM. IF YOU NEED ASSISTANCE PLEASE CALL 1-866-22-GREEK. I the undersigned authorize these charges and fully agree to the Terms and Conditions stated at stuff4greeks. com* Sign your name or type your initials here. cardholder s signature SAVE PRINT SUBMIT BY EMAIL If this is a group order complete page 2 before you submit. contact person email address organization chapter name SIZE LINE FIRST NAME LAST NAME LINE NAME other. crossing jacket RIGHT SLEEVE stuff4GREEKS*com the paraphernalia of choice lowercase UPPERCASE 1. Click on the picture and type or describe what you want in each area* Use UPPERCASE for Greek letters lowercase for regular letters. TM a b c d e f g h i j k l m n o p q rst u v wx y z A B C D EF G H I J K L M N OPQ RS T UV W X YZ COLLAR 2.

Request for applicants job ord... Request for Applicants / Job Order Form To help us serve you better, please complete this Job Order Form and contact your local WorkSource office to speak with a qualified business representative.

Field trip lunch order formpdf... SD MBU SACK LUNCH FORM Staple to Field Trip Permission Slip and turn in to the school office at Least 3 DAYS BEFORE the Field Trip FIELD TRIP DATE: SCHOOL: $ 3.50 Elementary School $ 4.00 MBMS &

Esperance primary school unifo... 2014 Esperance Primary School P C SCHOOL UNIFORM ORDER The Uniform Shop is open on Tuesdays 8. 30 9. 45 am A 30 DEPOSIT OR 20 is required on all orders. If deposit paid only the uniforms will be left in the office for remaining payment and pickup* If full payment is received with your order we will deliver the items to your child s classroom* PARENT/CARER NAME Phone Number Eldest Child s Name Room Number Colour Price Zip Front Windcheaters Royal Blue with logo n/a Eureka Polo Shirts with White logo White with Royal with white pin stripe Eureka Jacket Wet Weather Jackets Polar fleece lined Track Pants fleecy Track Pants - microfibre Microfibre Bucket Hat One Size Fits All Tartan Skirt New style Bootleg Pants 2-8 10-16 Tights sml med lg Navy Microfibre skirt with built in bike pants Long Leg Cargo Trousers D/Knee Gaberdine Pants Boys Girls Podium Shorts Total Uniforms can now be paid via EFT to BSB 036150 Acc 150965 Description U/F then your surname. Orders must be accompanied by a copy of the EFT receipt as proof of payment or the order will not be processed* All prices subject to change. 45 am A 30 DEPOSIT OR 20 is required on all orders. If deposit paid only the uniforms will be left in the office for remaining payment and pickup* If full payment is received with your order we will deliver the items to your child s classroom* PARENT/CARER NAME Phone Number Eldest Child s Name Room Number Colour Price Zip Front Windcheaters Royal Blue with logo n/a Eureka Polo Shirts with White logo White with Royal with white pin stripe Eureka Jacket Wet Weather Jackets Polar fleece lined Track Pants fleecy Track Pants - microfibre Microfibre Bucket Hat One Size Fits All Tartan Skirt New style Bootleg Pants 2-8 10-16 Tights sml med lg Navy Microfibre skirt with built in bike pants Long Leg Cargo Trousers D/Knee Gaberdine Pants Boys Girls Podium Shorts Total Uniforms can now be paid via EFT to BSB 036150 Acc 150965 Description U/F then your surname. Orders must be accompanied by a copy of the EFT receipt as proof of payment or the order will not be processed* All prices subject to change.

Transcript purchase order thir... Part I. (To be completed by party responsible for ordering transcript) ... This is to order a transcript of the proceedings heard on the date listed below from.

Recruiting form 2010docx quoth... SAILING RECRUITING PROFILE www.odusports.com PHONE (757) 683-3387; FAX (757) 683-6124 Mitch Brindley, Head Sailing Coach, mbrindle odu.edu Charles Higgins, Assistant Sailing Coach, chiggins odu.edu

Visa order form g3 visas amp p... INDIA Tel: 866.945.8472 Fax: 866.611.6960 NationalGeographic g3visas.com Business Hours: 8am - 9pm EST Rail Journey Through India Visa Instructions STEP 1: Please complete this order form (one per

Chipotle menu template form Fax order to 970-407-1447 Then please call 970-407-1446 to confirm your order. 1 start here (please print) date CSU 649 South College Avenue 11a.m. to 10 p.m. D 3 PLEASE CALL TO CONFIRM YOUR ORDER.

Doterra product order form WHOLESALE PRODUCT ORDER FORM - US Name Wellness Advocate # Email Shipping Address Qty City, State Code Essential Oils Unit Phone # Retail Wholesale PV TOTAL Certified Pure Therapeutic Grade Essential

Infusion form FAX BACK INFUSION CONFIRMATION Please update the referring physician by faxing back this form. Date of Infusion Infusing physician comments Important Safety Information is contraindicated in patients with hypocalcemia or hypersensitivity to any component of this product. FAX REFERRAL FORM Referring physician s name 5 mg/100 mL for infusion One Infusion. Yearlong Osteoprotection. Dear Doctor/Infusion Center I am referring my patient to you for a infusion. Patient name PATIENT INFORMATION J-3488 J code SS with patient permission Patient address Patient phone Diagnosis Postmenopausal osteoporosis Paget s disease of the bone 731. 0 ICD-9 This patient has a calculated creatinine clearance of 35 mL/min and a normal serum calcium level* Yes No Date of lab results Policy Group / Policy holder Phone Secondary Insurance Primary Insurance INSURANCE 733. 01 Patient currently taking calcium and vitamin D supplements. DIAGNOSIS Date of birth Attach copies of the following Lab results Prescription Insurance card s front and back Date Physician s signature A copy of this information can be given to the patient to bring to his or her appointment. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A. 0 ICD-9 This patient has a calculated creatinine clearance of 35 mL/min and a normal serum calcium level* Yes No Date of lab results Policy Group / Policy holder Phone Secondary Insurance Primary Insurance INSURANCE 733. 01 Patient currently taking calcium and vitamin D supplements. DIAGNOSIS Date of birth Attach copies of the following Lab results Prescription Insurance card s front and back Date Physician s signature A copy of this information can be given to the patient to bring to his or her appointment. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A. contains the same active ingredient found in acid Injection and patients receiving should not receive . All patients should be instructed on the importance of calcium and vitamin D supplementation* Please refer to full Prescribing Information for recommendations. Please see accompanying full Prescribing Information* Novartis Pharmaceuticals Corporation East Hanover NJ 07936 2008 Novartis Printed in U*S*A.

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