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032-05-076d4-01 Physicians Oral PRN Order
VDSS MODEL FORM - ADCC. DOCUMENTATION OF PHYSICIANS ORAL ORDER. FOR PRN (AS NEEDED) MEDICATION. NAME OF PARTICIPANT:
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NYS Medicaid Prior Authorization Request Form For
Yes. No. If no, supply administering provider: Please check one of the following: This is a new medication and/or new health plan for the
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Medication Order Form
Mail this completed order form, with your prescription and payment information, to: Birdi, PO BOX 8004, Novi, Michigan 48376-8004. Ask your doctor to send
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