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Get Form Hcp 65 Ri

The following month NAME ADDRESS CITY STATE ZIP CODE PHONE NUMBER FEDERAL EMPLOYER IDENTIFICATION NUMBER RETURN FOR THE PERIOD OF: MONTH YEAR Calculation of Amount Due: 1. Net patient imaging revenue received ........................................................................................................ 1. 2. Imaging services surcharge - line 1 time 2% (0.02) ................................................................................... 2. 3. Interest - (1.5% per month) see i.

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