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Get and Sign Helathways Pt Auth Form 2012-2022
Condition new recurring or chronic. X. new. X. recurring. X. chronic What type of injury or condition is this request related to check all that apply. X. work. X. auto. X. other injury. X. post surgery. X. none How long has the patient had this condition. X. 1mo X. 1-3 mo X. 3 mo What is the Initial Date you began treating this patient for this episode of care Have you or anyone in your facility provided treatment to this patient within the past 6 months for any condition How many visits are...
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