UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM BUTALBITAL-CONTAINING PRODUCTS Patient name:___________________________________Medicaid ID - Barbiturates - Document - PDFSEARCH.IO

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	UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM BUTALBITAL-CONTAINING PRODUCTS Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________ Add to Reading List Document Date: 2014-08-07 16:26:15 Open Document File Size: 111,53 KB Share Result on Facebook Facility Pharmacy Phone# / / IndustryTerm combination product / migraine treatment / / MedicalCondition migraine / / Organization DEPARTMENT OF HEALTH / / Person Trial / / Position physician / / Product Requested Medication / acetaminophen / BUTALBITAL / / SocialTag Alkenes Analgesics Morphinans Phenols Barbiturates Butalbital Paracetamol Codeine Aspirin Chemistry

UTAH DEPARTMENT OF HEALTH, PRIOR AUTHORIZATION REQUEST FORM BUTALBITAL-CONTAINING PRODUCTS Patient name:___________________________________Medicaid ID #:________________________________ Prescriber Name:_________________Add to Reading List