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Get and Sign Network Health Admission Surgery Notification Form 2009-2022
Phone
-
-
Fax
Network Health provider ID # or billing ID #
-
-
Tax ID #
Member diagnosis with ICD-9 code
Procedure performed with CPT code
Hospital name
Length of stay
Hospital ID #
Hospital tax ID #
Floor/room number
UR phone
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-
Contact name
Contact phone
-
-
Contact fax
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-
Hospital address
City
06159
Network Health Provider Manual 2009
State
Form available at www.network-health.org
ZIP
Attachment E
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