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THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. SIGNATURE OF PROVIDER DATE ATPT Form Version 1. DATE S OF TREATMENT REQUESTED 41. CHECK APPROPRIATE CARE PATH If applicable FROM TO CP1 CP2 CP4 CP3 CP6 CP5 42. REQUEST FOR SERVICES CPT / HCPS / NDC CODES FREQUENCY Times per visit Use left box for single codes or left and right box for a range of codes Visits per week DURATION Number of...
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