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Required Information Checklist

Clinical Records

  • Diagnosis Code/Date of Diagnosis
  • Height/Weight
  • History of Treatment
  • Failed Medications/Therapies
  • Previous Lab Work (Date of Last TB Test/HBV Test)
  • Any Other Pertinent Information supporting Patient’s Treatment Plan

Patient Information

  • Full Legal Name
  • Email and Phone Number
  • DOB
  • Address
  • Insurance Card (Front and Back)