SERVICE REQUEST FORM Connect
Page 3 of 4 SERVICE REQUEST FORM KRYSTEXXAConnect Please fax completed form with a copy of the front and back of the patient’s insurance card. Fax: 1-877-633-9522 • Phone: 1-877-633-9521 • Monday–Friday, 8:00 am–8:00 pm ET I hereby authorize my healthcare providers, my health insurance carriers, and my pharmacies to use and disclose my individually identifiable health
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