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Get Licensed Independent Practitioner's Rehabilitative Services Manual Manual Updated 02/01/13 Forms

5 Claim Adjustment Form 130 Medicaid Refunds DHHS 931 Health Insurance Information Referral Form 01/2008 Reasonable Effort Documentation 05/2007 Authorization Agreement for Electronic Funds Transfer 03/2011 Duplicate Remittance Advice Request Form 10/2012 Sample Claim Showing TPL Denial with NPI 08/2005 Sample Edit Correction Form 10/2008 Sample Remittance Advice (three pages) 06/2007 Referral Form/Authorization For Rehabilitative Services 02/2013 Psychological Testing/Evaluat.

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