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PATIENT DOB SEX HEIGHT WEIGHT pounds. DATE OF SERVICE AND NPI Indicate the name of the DME company Provider name Provider s DME and NPI. 50 42. 75 P 1112233333 M S0315 142. 50 42. 75 P S9445 859. 00 AB11110000 ADJUSTMENTS F M O CHECK ORIGINAL CCN 513. 71 P S9445 392. 00 126. 00 P VOID OF ORIGINAL CCN 13283002244813300A PAID 20131018 1412. 00- 273. 71- P 1112233333 M 100213 S0315 1112. 00- 197. 71- P 1112233333 CLARK M 131018 1328300224813300A S0315 453. 00 160. 71- P S9445 60. 00 33. Enter a...

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