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Ursing Inpatient Rehabilitation Other Section A: Client Information Client Name (Last, First, MI): Medicaid Number (PCN): Date of Birth: / / Section B: Supplier/Vendor/Qualified Rehabilitation Professional (QRP) Information Supplier Name: Telephone: Fax Number: Supplier Address: TPI: NPI: Taxonomy: QRP Name: Benefit Code: QRP TPI: QRP NPI: Section C: Diagnosis and Medical Necessity of Requested Services Section D: Dates of Service and HCPCS Code Dates of Service HCPCS Cod.

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