Form Frx0025 - Prior Authorization Request Form For Lotronex (Alosetron) Page 2

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Fax completed forms to (866) 284-4509.
For Office Use Only
Date/Time Received_____________________________________________________________________
Reference Number______________________________________________________________________
Approved / Denied (Circle One) by _____________________________ Date_______________________
Date/Time Returned to Provider___________________________________________________________
If you have any questions regarding this form, contact the Prior Authorization Department Toll Free at
(866) 284-4492 or FAX Toll Free at (866) 284-4509.
FOX Rx Care Utilization Management
3375-I Capital Circle NE
Tallahassee, FL 32308
IMPORTANT NOTICE: This facsimile is intended to be delivered to the named addressee and may contain material that is confidential, privileged, proprietary or exempt from disclosure and
applicable law. If it is received by anyone other than the named addressee, the recipient should immediately notify the sender at the address and telephone number set forth herein and obtain
instructions as to disposal of the transmitted material. In no event should such material be read or retained by other than the named addressee, except by express authority of the sender to the named
addressee.
Lotronex (alosetron)

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