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Get NY C-5 2015-2024

I L From DD L MM I N G 4. B Dates of Service To YY MM DD YY C Place Leave of Blank Service D (USE WCB CODES) Procedures, Services or Supplies (Explain Unusual Circumstances) CPT/HCPCS MODIFIER E F Diagnosis Code $ Charges G H Days or COB Units I Zip Code Where Service was Rendered F O R M C R 13. In your opinion, was the occurrence described above (or in your previous report which gave this information) the competent producing cause of the injury or disease? YES S I G N A T U.

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