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Patient indicate this by placing date MM/DD/YY needed initially in the space TYPE/ 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. 03A SECTION A Certification Type/Date INITIAL // REVISED // RECERTIFICATION// PATIENT NAME ADDRESS TELEPHONE and MEDICARE ID SUPPLIER...

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