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Get OH C-19 2010-2024

Ion to the local customer service office. • For instructions on how to complete this invoice, refer to the BWC's Billing and Reimbursement Manual. 5. Injured worker's name (last, first and middle initial) 7. Referring physician provider number 10. Patient account number (15 max) Nursing Practitioner Vocational rehabilitation Other vendor 4. Date of injury 6. Injured worker's address (street or P.O. Box, city, state and ZIP code) 9. Prior authorization number (if applicable) 8. Ref.

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