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150 Houston TX 77080 Tel 713 425-8119 l MRI MRA X-Ray Ultrasound 5630 E. Sam Houston Pkwy N. MR Arthrogram CT 1336 Pin Oak Road Katy TX 77494 1733 Woodstead Ct. Phone 713. 425. 8100 Fax Orders 713. 425. 8182 www. HoustonMRI. com Order Date SELECT LOCATION q West Houston Patient s Name q East Houston Phone q The Woodlands DOB ID q Insurance q Katy Sex Group q Attorney Name Phone q W / C Claim ID Physician Print Physician Signature Specialty Fax REPORT REQUEST q Web PACS IMAGE ACCESS q Report...
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Phone 713 is a form used for reporting certain financial information to the relevant authorities.
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