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Name of the billing provider or facility as it will appear on the claim form 2. Federal tax ID TIN of entity in box 1 MD/DO 4 OT 5 Both PT and OT 6 Home Care 7 ATC DC 3 PT 8 MT 9 Other 3. Patient Summary Form Instructions Please complete this form within the specified timeline and fax to the specified fax number as indicated on Plan Summary or plan information previously provided. PSF-750 Rev 2/18/2009 Patient Information Patient name Female Last First Male MI Patient date of birth Fax number...
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