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Get CMS-116 2014

Ian Office Is this a shared lab? Yes No 22 Practitioner Other (Specify) ______________________________ 23 Prison 24 Public Health Laboratories 25 Rural Health Clinic 26 School/Student Health Service 27 Skilled Nursing Facility/ Nursing Facility 28 Tissue Bank/Repositories 29 Other (Specify) ______________________________ (List times during which laboratory testing is performed in HH:MM format) If MONDAY TUESDAY WEDNESDAY THURSDAY testing 24/7 Check Here FRIDA.

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