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Get 848 09 2017-2024

ANEOUS ELECTRICAL NERVE STIMULATOR (TENS) SECTION A: Certification Type/Date: INITIAL ___/___/___ REVISED ___/___/___ RECERTIFICATION___/___/___ PATIENT NAME, ADDRESS, TELEPHONE and MEDICARE ID SUPPLIER NAME, ADDRESS, TELEPHONE and NSC or NPI # (__ __ __) __ __ __ - __ __ __ __ Medicare ID _______________________ (__ __ __) __ __ __ - __ __ __ __ NSC or NPI #_________________ PLACE OF SERVICE ______________ Supply Item/Service Procedure Code(s): PT DOB ____/____/____ Sex ____ (M/F) Ht. ___.

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