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Get MARYLAND MEDICAL ASSISTANCE PROGRAM BILLING ... - Mmcp Dhmh Maryland

Tion Sample UB04 UB04 FORM LOCATORS Billing Provider Name, Address, and Telephone Number FL 01 Pay-to Name and Address FL 02 Patient Control Number FL 03a Medical/Health Record Number FL 03b Type of Bill FL 04 Federal Tax No FL 05 Statement Covers Period (From - Through) FL 06 Reserved for Assignment by NUBC FL 07 Patient Name Identifier FL 08 Patient address, city, State, zip code, and county code FL 09 Patient Birth Date FL 10 Patient Sex FL 11 Admission/Start of Care Date FL 12 Admission.

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