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G PROVIDER INFORMATION Requesting Physician: Tax ID: Contact Person: Phone: Facility Name: Facility Tax ID: Specialty (type): Fax: Contact Person: SECTION III: TYPE OF CARE REQUEST Routine Urgent Emergent Diagnosis: (ICD 9 Code/Description): Date of Service and/or Anticipated Length of Care: Requested Services or Procedures: CPT/HCPCS Code/Description: SECTION IV: TYPE OF SERVICES REQUESTED In-Patient Admission: In-Office Procedure PT / OT Acute Care Rehab SNF BH Labs Speech The.

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