Botox CCRD Prior Authorization Form

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an otolaryngologist? Yes No (if sialorrhea) Is the requested drug being prescribed by, or in consultation with an endocrinologist, a neurologist, or an otolaryngologist? Yes No (if fistula) Has your patient had failure to pharmacotherapy (including anticholinergics)? Yes No (if sialorrhea) Is there documentation that your patient has failure ...

  Otolaryngologist