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Get Amerigroup PF-ALL-0077-12

Er Name: Phone #: Provider ID #: Date of Birth: Fax #: Date of Visit: Address: Preventive/Physical Age New Established Code Length of Time Patient Patient 12 17 99384 99394 99201 99211 99401 15 minutes 18 39 99385 99395 99202 99212 99402 30 minutes 40 64 99386 99396 99203 99213 99403 45 minutes 65+ 99387 99397 99204 99214 99404 60 minutes 99205 99215 Diagnosis Codes: Please indicate primary, secondary, and tertiary codes (1, 2, 3). *If elements of well care were performed, please mark.

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