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Get CMS-116 2007

12 ❏ 13 ❏ 14 ❏ 15 ❏ 16 ❏ 17 ❏ 18 Health Fair Health Main. Organization Home Health Agency Hospice Hospital Independent Industrial Insurance Intermediate Care Facility for Mentally Retarded ❏ 19 Mobile Laboratory ❏ 20 Pharmacy ❏ 21 Physician Office ❏ 22 Practitioner Other (Specify) _________________________ ❏ 23 Prison ❏ 24 Public Health Laboratories ❏ 25 Rural Health Clinic ❏ 26 School/Student Health Service ❏ 27 Skilled Nursing Facility/ Nursing .

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