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Ax www.rehabdocumentation.com Plan of Care Occupational Therapy Patient Name: Medical Record #: Account #: Provider: Provider #: Treating Clinician: Page 1 of 2 Date: 1/17/2011 12:18 PM DOB: 1/14/2005 SOC Date: 1/17/2011 Smith, Charlie CB549 74348290 Action Rehabilitation Services 17238940 Olivia Orin, MS, OTR/L Medicare #: NA Medicaid #: 17238470 Visits From SOC: 1 Onset Date Primary Diagnosis: Other Diagnosis: (Initial Evaluation) Code 2/14/2005 12/22/2010 783.42 781.3 Descrip.

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