Fillable 8664809903 form

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First Health Services Phone: (800) 525-2395 Fax: (866) 480-9903 SCREENING REQUEST for PEDIATRIC SPECIALTY CARE SERVICES Name of Nursing Facility: Resident Name: Pediatric Specialty Care I or Request for: Initial Approval Medicaid #: Pediatric Specialty Care II - Mechanical Ventilator Dependent or Continuing Approval Nursing Services: 1. The patient's condition requires twenty-four (24) hour access to nursing care...
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8664809903
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