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Get and Sign FAX 780 427 5863 2020 Form

Get and Sign FAX 780 427 5863 2020 Form

Use a FAX 780 427 5863 2020 template to make your document workflow more streamlined.

Rate per Unit Fee Submitted Total Amount Billed Sundry Items Name and Address to Whom Fee is Payable Provider Name Print Name WCB Billing Number Fax Number Provider Reference Number NOTE PLEASE SEE REVERSE FOR SERVICE LEGEND THIS DOCUMENT MAY BE EXAMINED BY ANY PERSON WITH DIRECT INTEREST IN A CLAIM THAT IS UNDER REVIEW. C - 019 REV JUNE 2020 Page 1 of 2 Physical Therapy Services Invoice SERVICE LEGEND Health Service Code RF04 RF05 RF06 NCPTS Service Fee Effective February 1 2017 Chart Copies...
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