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Prescriber section (your health-care providers responsibility) Your health-care provider must complete the second part of the application: Provide prescription details: medication name, dosage, frequency, and refill quantity Sign the Provider Declaration, stating: The medication is medically necessary It will be dispensed to you at no charge Step 5: Submit the application Once youve completed the application and gathered all required documentation, the next step is to submit it to Novo Nordisk for review

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