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F245 056 000  Form

F245 056 000 Form

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Number Agency’s Name (If applicable) Agency’s Group Number Appointment Information Type of appointment – write the type of appointment such as diagnostic, doctor, vocational, etc. Appointment Date (Use the mm/dd/yyyy format) / Language Requested / Healthcare or Vocational Provider’s Name (Last Name, First Name) Billing Information Is this a group service? No Yes Is this the first or last appointment of the day? Number of people in the group No – will need to prorate...
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