Prior Authorization Page 4
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PRIOR AUTHORIZATION DRUG ATTACHMENT FOR MODAFINIL AND NUVIGIL
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F-00079 (01/2017)
SECTION IV – AUTHORIZED SIGNATURE
35. SIGNATURE – Prescriber
36. Date Signed
SECTION V – ADDITIONAL INFORMATION
37. 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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Parent category: Medical