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Get Al Form 369 2008

48-0116 Phone: (800) 748-0130 Fax or Mail to Health Information Designs ❒ Page 1 of 2 P.O. Box 3210 Auburn, AL 36823-3210 PATIENT INFORMATION Patient name Patient Medicaid # Patient DOB Nursing home resident ❒ Yes Patient phone # with area code PRESCRIBER INFORMATION NPI # Prescriber name Phone # with area code License # Fax # with area code Address (Optional) Street or PO Box /City/State/Zip I certify that this treatment is indicated and necessary and meets the guidelines for u.

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