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This form is to be used to seek reimbursement from ConnectiCare for prescription drug costs you paid above the cost-share amounts outlined under your plans
NEW PATIENT FORM. PATIENT We will contact your current pharmacy to transfer any active prescriptions that they have for you to the AU Employee Pharmacy.
NEW PATIENT MAIL ORDER PHARMACY ENROLLMENT FORM. Please fax or email the completed form to (310) 669-5609 or priorauth@dhs.lacounty.gov. Attachment J. PATIENT
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