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Step 1: Initially, select the orange "Get form now" button.
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These particular parts will make up the PDF document:
Enter the requested information in the area PHYSICIAN Please ﬁll out Section, If you have received this document, Physician Name, Street Address, City State ZIP, Physician Signature, ORXFE, Reﬁlls, Other, Dispense as written, Yes, Ofﬁce Phone Number with Area Code, Fax Number with Area Code, NPI, and Date.
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