P: 855-900-8414-2025

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The document is a Cardiology Referral Form used by prescribers to refer patients for cardiology services. It includes sections for prescriber and patient information, clinical details such as diagnosis codes and current medications, prescription information with dosage instructions, and consent for Universal Specialty Pharmacy to act on behalf of the prescriber regarding insurance matters. The form emphasizes the need for confidentiality and compliance with HIPAA regulations.

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