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Physician Order - Diabetic Form Fax form with physician's signature & date to 1-866-855-5888 (toll free fax) Required Start Date: Patient Medicare ID: Patient Name: Address: City: Phone#: State: Physician Order - Diabetic Form Fax form with physician's signature & date to 1-866-855-5888 (toll free fax) Required Start Date: Patient Medicare ID: Patient Name: Address: City: Phone#: State:
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