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Get NC NHRMC VL-007 2009-2024

_________________________ Physician Certification Statement for Medical Transport Complete for non-emergency scheduled and non-emergency unscheduled ambulance transport(s) SECTION I - GENERAL INFORMATION Patient's Name: ______________________________________ Return to prior arrangement: _____________ New Placement:_______________ Initial Transport Date: ___________________ Repetitive Transport Expiration Date (Max 60 Days From Date Signed): ____________________ Origin: ________________________.

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