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78\u003C176;􀀓  \n\n| 􀀘5/)41\u003CAC 1; 16,1+)\u003C-, .7: \u003C0-8:->-6\u003C1>- \u003C:-)\u003C5-6\u003C 7. 51/:)16-16 ),=4\u003C;􀀇 |\n| --- |\n| ((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( |\n| 􀀍\" 􀀛􀀙'􀀞\\#\" 􀀊􀀛)􀀞􀀙􀀛􀀇 􀀃+077;-76-􀀄􀀓 F 8:-.144-, 8-6 􀀃􀀊􀀋􀀉 5/􀀈5􀀝􀀄 7: F 8:-.144-, ;A:16/- 􀀃􀀊􀀋􀀉 5/􀀈5􀀝􀀄\u003Cbr>􀀏\\#\"'􀀝 􀀆 􀀎\\#􀀗􀀚􀀞\"􀀜 􀀊\\#&􀀛􀀇 F 􀀋􀀍􀀉 5/ 􀀃􀀋 @ 􀀊􀀋􀀉 5/􀀄 ;=*+=\u003C)6-7=; 162-+\u003C176 & 􀀊 􀀃􀀗1;8-6;- 􀀋 ,->1+-; ?1\u003C0 􀀞7 \"-.144;􀀄\u003Cbr>􀀆􀀈􀀇􀀇􀀈􀀉􀀅􀀄 􀀃􀀊􀀂\u003Cbr>􀀏\\#\"'􀀝 , 􀀏􀀗􀀞\"'􀀛\"􀀗\"􀀙􀀛 􀀊\\#&􀀛􀀇 F 􀀊􀀋􀀉 5/ ;=*+=\u003C)6-7=; 162-+\u003C176 576\u003C04A 􀀃􀀗1;8-6;- 􀀊 ,->1+-8-: 576\u003C0􀀄 |\n\n􀀂􀀃  \n\n| 􀀘5/)41\u003CAC 1; 16,1+)\u003C-, .7: \u003C0- \u003C:-)\u003C5-6\u003C 7. -81;7,1+ +4=;\u003C-: 0-),)+0-16 ),=4\u003C;􀀇 |\n| --- |\n| (((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((((( (((((((((((((((((((((((((((( ((((( |\n| 􀀍\" 􀀛􀀙'􀀞\\#\" 􀀊􀀛)􀀞􀀙􀀛􀀓 F 8:-.144-, ;A:16/- 􀀃􀀊􀀉􀀉 5/􀀈5􀀝􀀄\u003Cbr>􀀏\\#\"'􀀝 , 􀀊\\#&􀀛􀀇 F 􀀌􀀉􀀉 5/ ;=*+=\u003C)6-7=; )\u003C \u003C0- ;\u003C):\u003C 7. ) +4=;\u003C-: +A+4- 􀀃),5161;\u003C-:-, ); \u003C0:-- +76;-+=\u003C1>-162-+\u003C176; 7. 􀀊􀀉􀀉 5/ -)+0􀀄\u003Cbr>)6, \u003C0-6->-:A 576\u003C0 ); 6--,-, =6\u003C14 \u003C0- -6, 7. \u003C0- +4=;\u003C-: +A+4- 􀀃􀀗1;8-6;- 􀀌 ,->1+-; 8-: 576\u003C0􀀄 |\n\n!=)6\u003C1\u003CA \u003C7 *- ,1;8-6;-,􀀓 / 􀀍 576\u003C0 ;=884A 􀀃5)@􀀄 / 􀀌 576\u003C0 ;=884A / 􀀋 576\u003C0 ;=884A / 􀀊 576\u003C0 ;=884A  \n\"-.144;􀀓 􀀂   􀀗)\u003C-􀀓    \n'7=: ;\u003C)\u003C-5)A :-9=1:- \u003C0)\u003C 8:-;+:18\u003C176; .7447? 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A7= :-+-1>-, \u003C01;,7+=5-6\u003C 16-::7:􀀅 84-);-67\u003C1.A =; 155-,1)\u003C-4A )6,,-;\u003C:7A \u003C0- :-4)\u003C-,,7+=5-6\u003C􀀇  \n􀀆􀀔 􀀆%\\#􀀆􀀉􀀌􀀎􀀐 􀀉􀀏􀀈􀀋􀀉􀀊􀀒 D 􀀝144A %\\#􀀔􀀅 􀀝􀀝􀀖 􀀋􀀉􀀊􀀒􀀇 􀀔44 :1/0\u003C; :-;-:>-,􀀇 􀀘5/)41\u003CAC 1; ) :-/1;\u003C-:-, \u003C:),-5):3 7?6-, 7: 41+-6;-, *A 􀀘41 􀀝144A )6, 􀀖758)6A􀀅 1\u003C;;=*;1,1):1-; 7: )..141)\u003C-;􀀇","cbCaikvToYUggvdL","https://ap.wps.com/l/cbCaikvToYUggvdL","pdf",59547,"English","# Patient information\n## Prescriber information\n## Authorization and submission","[{\"question\":\"What is the purpose of this document?\",\"answer\":\"It is a prescription fax form used for Emgality requests under the Lilly Cares program, collecting required details for submission.\"},{\"question\":\"What information must be completed?\",\"answer\":\"The form requires structured patient and prescriber fields, along with required declarations and authorization elements.\"},{\"question\":\"How is the form meant to be submitted?\",\"answer\":\"The document provides instructions for fax submission after completing all required sections and providing any necessary signatures.\"}]","lilly_cares_prescription_fax_form_emgality | PDF",1789841764]