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Get Fidelis Care Postpartum Encounter Form (Attachment B) 2018

Submit this encounter form (no later than 14 weeks from delivery date) by mail or fax to 1-866-815-7223.The encounter form must be signed and dated. Group Name Provider Name Tax Identification # (must be completed) Member Name Member ID # Member Phone # / / Member Date of Birth / / Date of Delivery / / EDC PROVIDER.

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