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Enhanced Primary Care (EPC) Program
Referral Form for Allied Health Services under Medicare
THIS FORM MUST ACCOMPANY ALL MEDICARE CLAIMS. SEE PART C BELOW.
CLINICAL NOTES SHOULD NOT BE WRITTEN ON
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What is this form must accompany?
This form must accompany any tax filings.
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Any individual or business entity required to file taxes.
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The purpose of this form is to provide additional information or documentation to support the tax filings.
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Any relevant information or documentation requested by the tax authorities.
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