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Shl.uiowa.edu State Hygienic Laboratory Hospitalized in-patient Patient s Medicaid/Medicare Physician Provider ICD9 Diagnosis Code REQUIRED International Travel days Referring Physician Medipass only Influenza Vaccination If insurance is primary to Medicaid / Medicare Started Antibiotic / Antiviral Insurance Company Name City Live Killed Injection Insured s Name Insured s ID Type State Zip Facility Name Enter your facility address Address...
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