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3133 PROFESSIONAL DRIVE #17 AUBURN, CA 95603
PHONE: 530-885-8582 │ FAX: 530-885-8593 OR 888-696-6055 │
Patient Name: _________________________________________________________
City, State,Zip: _________________________________________________________
Prescriber Name: _________________________________________________
Phone: _________________________________ Fax: _______________________________
City, State, Zip: ___________________________________________________
Contact Person: __________________________
ICD-9 Code: � ______________________ Diagnosis: _____________________________________________________ Serum Creatinine: ____________________________CD4 Count: __________________________ Viral Load: _____________________________________________________ Lab date: ___________________________________
� Sustiva 600mg tab (take at bedtime)� Isentress 400mg tab
� Trizivir 300/150/300mg tab� Prezista ________ mg tab
� Take ______ tablets ____________ times per day
By signing below, the prescriber gives consent to both, the prescription(s) above, as well as to Greater Placer Pharmacy to act as the prescriber's agent to begin and execute theprior authorization process and to help the patient apply to co-pay assistance programs, including all foundations and manufacturer assistance programs if necessary.
By signing below, I authorize Greater Placer Pharmacy to help me enroll in any or all patient co-pay assistance programs, including all foundations and manufacturer assistanceprograms. I authorize any communications among my providers, the pharmacy and the manufacturers regarding my health conditions and medications prescriptions in order tohelp coordinate the delivery of products and services through the various co-pay assistance programs. I understand that I may refuse to sign this form without affecting myability to obtain treatment from the pharmacy. However, my refusal will not allow me to be enrolled in any co-pay assistance programs. If agreed, this signed authorization form(or a copy of this form) will be utilized as the original signed application for any and all possible foundations that may participate in the co-pay assistance programs, and it mayserve such purpose.
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Overview Our trek dates are inclusive of travel time to and from North America. We are happy to make additional transport and hotel reservations if you are arriving early or staying late. As trips to Patagonia may require pre-trip preparation, we will work with you to ensure you have the proper health requirements, airline reservations and visas. Arrival in Patagonia Berg Adventures will pick you
LE CARATTERISTICHE DEI BACINI IDROGRAFICILE CARATTERISTICHE DEI BACINI IDROGRAFICIIl territorio dell’AdB della Basilicata comprende sei bacini idrografici, checostituiscono il più significativo e concentrato tributo idrico al mare Joniodell’intero versante Meridionale. Complessivamente esso ricopre una superficie di circa 8.830 kmq, nel-l’ambito della quale ricadono 118 comuni, appartene