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Pt ID
?
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Pt ID assign auth
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Organization EOC unique ID
?
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Federal employer tax ID Organization
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Name Facility
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Visit date
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{mm/dd/yyyy}
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Provider First name
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Provider Last name
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National provider ID:ID:Pt:Provider:Nom:
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Provider role
?
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Intervention or services provided pnl
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Billing info pnl
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Instructions provided
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Airway clearance technique perf
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Assistive technology prov
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Biophysical agent used
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Functional training perf
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Integ repair protect technique
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Manual therapy technique used
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Motor function training perf
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Ther exercise perf
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Other intervention or service provided
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Reason for referral:Find:Pt:^Patient:Nar:
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