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Get AR BCBS Inpatient Hospital Assessment Form For Acute Care Hospitals 2015-2024

First Name, Last Name: Subscriber #: Date of Birth: Facility Name: Contact Phone: Health Plan: Complete this form and fax it to: 1-844-869-4073 For readmissions within 14 days, please include the discharge summary from the first admission. Medi-Pak Advantage HMO Medi-Pak Advantage PPO 1. ER Admission: 2. CC: 3. PMH: 4. Vitals: 1 Revised September 2015 &tm T. Arkansas BlueCross BlueShield Arth:ieplndenl:UcenseeoftheBlueCrou81'1dBlueShieldAuociation Inpatient Hospital Assess.

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