Form F-11092 - Prior Authorization / Preferred Drug List (Pa/pdl) For Growth Hormone Drugs Page 3

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PRIOR AUTHORIZATION / PREFERRED DRUG LIST (PA/PDL) FOR GROWTH HORMONE DRUGS
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F-11092 (10/13)
SECTION IV — AUTHORIZED SIGNATURE
22. SIGNATURE — Prescriber
23. Date Signed
SECTION V — FOR PHARMACY PROVIDERS USING STAT-PA
24. National Drug Code (11 Digits)
25. Days’ Supply Requested (Up to 365 Days)
26. NPI
27. Date of Service (MM/DD/CCYY) (For STAT-PA requests, the date of service may be up to 31 days in the future and / or up to 14
days in the past.)
28. Place of Service
29. Assigned PA Number
30. Grant Date
31. Expiration Date
32. Number of Days Approved
SECTION VI — ADDITIONAL INFORMATION
33. Include any additional information in the space below. Additional diagnostic and clinical information explaining the need for the
drug requested may also be included here.
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