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DENTAL OFFICE HOSPITAL ECF 35. NUMBER OF ENCLOSURES RADIOGRAPHS PATIENT/GUARDIAN SIGNATURE DIGITAL IMAGES MODELS DATE 36. DATE OF BIRTH 13. GENDER 14. SUBSCRIBER ID SSN OR ID M F 15. CLIENT NUMBER 16. EMPLOYER NAME PATIENT INFORMATION GENDER SUBSCRIBER/POLICYHOLDER ID SSN OR ID 17. DATE OF SERVICE 23. AREA OF ORAL MM/DD/CCYY 24. TOOTH NO. OR CAVITY 25. TOOTH LETTER 26. CURRENT CDT SURFACE 27. In addition an insurer may deny insurance benefits if false information materially related to a claim...
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