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Get CMS-701 1991-2024

S-700 or 701 is required.) 1. PATIENT’S LAST NAME FIRST NAME M.I. 2. PROVIDER NO. 3. HICN 4. PROVIDER NAME 5. MEDICAL RECORD NO. (Optional) 6. ONSET DATE 7. SOC. DATE 8. TYPE ■ PT 9. PRIMARY DIAGNOSIS (Pertinent Medical D.X.) 10.TREATMENT DIAGNOSIS 11. VISITS FROM SOC. ■ OT ■ SLP ■ CR 12. FREQ/DURATION (e.g., 3/Wk. x 4 Wk.) ■ RT ■ PS ■ SN ■ SW 13. CURRENT PLAN UPDATE, FUNCTIONAL GOALS (Specify changes to goals and plan.) GOALS (Short Term) PLAN OUTCOME (Long Te.

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