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Get HHS CMS-849 1996

Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ PATIENT NAME, ADDRESS, TELEPHONE and HIC NUMBER SUPPLIER NAME, ADDRESS, TELEPHONE and NSC NUMBER (__ __ __) __ __ __ - __ __ __ __ HICN (__ __ __) __ __ __ - __ __ __ __ NSC # PLACE OF SERVICE HCPCS CODE: NAME and ADDRESS of FACILITY if applicable (See PT DOB ____/____/____; Sex ____ (M/F) ; HT.______(in.) ; WT._____(lbs.) PHYSICIAN NAME, ADDRESS (Printed or Typed) Reverse) PHYSICIAN'S UPIN: PHYSICIAN'S TELEPHONE #.

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