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(place patient label here) Patient Name: Order Set Directions: () Check orders to activate; Orders with prechecked box will be followed unless lined out. Initial each place in the preprinted order
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It is a form used to report orders or benefits.
Employers or organizations providing orders or benefits must file.
You can fill out the form online or manually and submit it as directed.
The purpose is to report orders or benefits provided to individuals.
Information such as the amount, nature, and recipient of the orders or benefits.
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