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Inas Center for Medical Excellence (CCME) via fax at 877-272-1942or mail: CCME, ATTN: IHC Independent Assessment, 100 Regency Forest Drive, Suite 200, Cary NC 27518-8598. For questions, contact CCME at 800-228-3365 or IHCAssessment thecarolinascenter.org. Referral Entity: PCP Attending MD Date of Referral: / / (mm/dd/yyyy) Section A. Recipient Demographics Medicaid ID#: Recipient Name (as shown on Medicaid Card) First: MI: L.

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