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Get CMS-485 (C3) 1994

Equency/Route (N)ew (C)hanged Date 12. ICD-9-CM Surgical Procedure Date 13. ICD-9-CM Other Pertinent Diagnoses Date 14. DME and Supplies 15. Safety Measures: 16. Nutritional Req. 17. Allergies: 18.B. Activities Permitted 18.A. Functional Limitations Amputation 1 Bowel/Bladder (Incontinence) 2 3 Contracture 4 Hearing Paralysis 5 6 Endurance 7 Ambulation 8 Legally Blind 1 Complete Bedrest A B Dyspnea With Minimal Exertion Other (Specify) 2 Bedrest BRP 6 7 Independent At.

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