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Get Hhc Request Online Form

(877) 433-7085 Fidelis Care Member Name(Last, First, M.I.): Questions: 888-343-3547 Patient / Member Information Fidelis Care Member ID #: Date of Birth(mm/dd/yyyy): Provider Information Name/Title: Address(City, State, Zip ): Phone # (include area code): Provider Tax ID #: Provider (NPI) #: Fax # (include area code): IPA Affiliation (if applicable): ICD 9 Code(s) and descriptions: HHC Services CPT/HCPCS Code(s) and descriptions: # of Visits requested: All prior visits used?(circ.

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