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Get MN BCBS X15718R05 2011-2024

Provider Name: Contact Name/Phone #: NPI #: Fax: Provider#: Patient Name: DOB: Subscriber/Enrollee: Current Clinical Findings Chief Complaint Identification #: Address: Gender: Occupation: Group #: Smoker: Y or N BP > 140/90 Y or N Chief complaint:___________________________________________________________________________ Initial date of service: ___ / ___ / ______ Patient’s rating on Pain Severity Scale: Phase of care: (circle one): Acute Chronic Recurrent Initial _____ / 10 Cur.

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