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Food Allergies/Special Diets Form
*FOOD ALLERGY(S)/INTOLERANCES/Special Diet: Please provide a medical statement describing the dietary restrictions due to the food allergy, diet and/or.
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nys medicaid program- enteral formula prior authorization
Please note: This form should only be used as a guide when accessing the automated system. Have alternatives such as dietary changes, instant breakfast
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Special Diet Form
May 17, 2021 sponsors must ensure that all USDA meal pattern and nutrient requirements are met. This form must be completed by a licensed physician
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