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Ct Person: Facility Name: Physician Tax ID: Phone: Facility Tax ID: Fax: Contact Person: Specialty: (type) SECTION III: REQUESTED SERVICES INFORMATION Radiology / Imaging : CPT code Inpatient Admission: Acute Care Rehab SNF In-Office Procedure: CPT code(s) Labs Surgical / Diagnostic Procedure: CPT code Speech Therapy Inpatient (must complete section VI) Outpatient Additional Office Visits (lis.

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