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Get Qualchoice Fax Assessment Form 2015-2024

Y in a facility. Please complete each field unless otherwise noted. Information must be legible. If not applicable; place N/A in the field. Incomplete submissions will be returned. Disclaimer Statements and Attestation Number of SNF days available: All therapy notes are within 24-48 hours of fax request. SNF member received at least 1 hour of therapy, 5 days a week. Acute rehab member is getting OT/PT at least 3 hours per day, 5 days a week and able to sit fo.

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