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Space marked INITIAL. If this is a revised certification to be completed when the physician changes the order based on the patient s changing clinical needs indicate the initial date needed in the space marked INITIAL and indicate the recertification date in the space marked REVISED. 03 Certification Type/Date INITIAL // REVISED // RECERTIFICATION// PATIENT NAME ADDRESS TELEPHONE and HIC NUMBER SUPPLIER NAME ADDRESS TELEPHONE and NSC or applicable NPI NUMBER/LEGACY NUMBER - HICN PLACE OF...