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Get and Sign Kid Care Chip Form
SERVICES Denial Termination Reduction Terminating EW Eligibility Reason Code DTR Comments e.g. date of Nursing Home admission/out of country date/services reduced via CL Tool If terminating EW Eligibility due to member s PCA hours please indicate this in the DTR comments Select Service Description Service Description select an option Frequency e.g. hrs per week/daily/monthly Rate Per Unit if negotiated Provider Name NPI Provider Phone Fax U7829 Page 1 of 2. Please complete the entire form....Show details
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