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Get CMS-671 2002

C Recreation Specialist F56 F57 F58 Qualified Activities Professional F59 Other Activities Staff F60 Qualified Social Workers F61 Other Social Services Dentists F62 F63 Podiatrists F64 Mental Health Services F65 Vocational Services F66 F67 F68 Speech/Language Pathologist Clinical Laboratory Services Diagnostic X-ray Services Administration & Storage of Blood Housekeeping Services Other F69 F70 F71 Name of Person Completing Form Time Signature Date Form CMS-671 (12/02) GE.

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