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Get Empire BCBS PHY 0744E-TWW 2006-2024

EPSDT OR FAMILY UNITS PLAN I J K EMG COB RESERVED FOR LOCAL USE 1 2 3 4 5 6 25. FEDERAL TAX ID NUMBER SSN EIN 26. PATIENT’S ACCOUNT NO. 27. ACCEPT ASSIGNMENT? YES 31. SIGNATURE OF PHYSICIAN OR SUPPLIER, INCLUDING DEGREES OR CREDENTIALS I CERTIFY THAT THE CARE, SERVICES AND SUPPLIES ENTERED ON THIS FORM HAVE BEEN RENDERED TO THE PATIENT, AND THAT I AM ENTITLED TO REIMBURSEMENT OF THE CHARGES INDICATED. SIGNED NO 32. NAME AND ADDRESS OF FACILITY WHERE SERVICES WERE RENDERED .

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