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3133 PROFESSIONAL DRIVE #17 AUBURN, CA 95603 PHONE: 530-885-8582 │ FAX: 530-885-8593 OR 888-696-6055 │ Patient Name: _________________________________________________________ Address: ______________________________________________________________ City, State,Zip: _________________________________________________________ Prescriber Name: _________________________________________________ Address: ________________________________________________________ Phone: _________________________________ Fax: _______________________________ City, State, Zip: ___________________________________________________ Contact Person: __________________________ ICD-9 Code: � ______________________ Diagnosis: _____________________________________________________ Serum Creatinine: ____________________________CD4 Count: __________________________ Viral Load: _____________________________________________________ Lab date: ___________________________________ � Sustiva 600mg tab (take at bedtime)� Isentress 400mg tab � Trizivir 300/150/300mg tab� Prezista ________ mg tab � Take ______ tablets ____________ times per day By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to Greater Placer Pharmacy to act as the prescriber's agent to begin and execute theprior authorization process and to help the patient apply to co-pay assistance programs, including all foundations and manufacturer assistance programs if necessary.
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By signing below, I authorize Greater Placer Pharmacy to help me enroll in any or all patient co-pay assistance programs, including all foundations and manufacturer assistanceprograms. I authorize any communications among my providers, the pharmacy and the manufacturers regarding my health conditions and medications prescriptions in order tohelp coordinate the delivery of products and services through the various co-pay assistance programs. I understand that I may refuse to sign this form without affecting myability to obtain treatment from the pharmacy. However, my refusal will not allow me to be enrolled in any co-pay assistance programs. If agreed, this signed authorization form(or a copy of this form) will be utilized as the original signed application for any and all possible foundations that may participate in the co-pay assistance programs, and it mayserve such purpose.
e This fax is intended to be delivered only to the named addressee and contains confidential information that is protected under
federal and state laws. If you are not the intended recipient, please notify the sender and destroy this document immediately.

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