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Get Dhs Form 470 2468 Rev 08 14

Pation Amount Situational Note: The total must include both dollars and cents (Example: $150.00). Failure to include both dollars and cents may result in a payment different from what you were expecting. SERVICES 12 Procedure Code REQUIRED Enter the five-digit service code for each service being billed on the claim. Note: Please do not include any dashes or punctuation within the procedure code. Leave blank, except when the Notice of Decision indicates that a procedure code modifier is nec.

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