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Functional Limitations ADLs and how impacted by deficit s Diagnoses causing these symptoms other Comorbidities and other Ambulatory assistance used if any. FAX Documentation Request Fax to Name Fax from Name Company Phone Fax Patient Date No. Pages We have received a referral to provide an Ottobock Agilium Freestep for the above patient. 45 CFR 164. 530 et seq. AgiliumFAX12296 Please fax the signed and dated Medical Necessity documents to. We appreciate your cooperation. History of Condition...
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