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Get Hi Dhs 204 2007-2024

Irth 3 Pharmacy Name 5 Pharmacy Address 6 Prescriber s NPI 7 Prescriber s DEA (for C II V drugs)8 Other Drug or Liability Coverage 10es No Name of Coverage Date of Accident 11 Prescriber s Name9 Is the illness or injury: 12 No Yes No Work Related Yes Automobile Third Party? Yes Yes Other Accident? No ICF-MR/ICF/SNF? 13 No No Submitted Charge27 Paid by TPL Amount 28 (Attach a copy of EOB).

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