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TELEPHONE and NSC or NPI - Medicare ID PLACE OF SERVICE Supply Item/Service Procedure Code s PT DOB // Sex M/F Ht. ATTESTATION The physician s signature certifies 1 the CMN which he/she is reviewing includes Sections A B C and D 2 the answers in Section B are correct and 3 the self-identifying information in Section A is correct. O1 o2 o3 Is the TENS unit being prescribed for any of the following conditions Check appropriate number 1 - Headache 2 - Visceral abdominal pain 3 - Pelvic pain 4 -...
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