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Specialized Transportation Form This form needs to be completed by the hospital/discharging facility that is determining the medical necessity of the transport / requested level of service. PATIENT

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What is as per your request?

As per your request is a specific requirement or action that needs to be completed based on a particular instruction or demand.

Who is required to file as per your request?

The individual or entity specified in the request is required to file as per the request.

How to fill out as per your request?

The specific instructions provided in the request must be followed to properly fill out as per your request.

What is the purpose of as per your request?

The purpose of as per your request is to ensure compliance with the requirements or instructions provided.

What information must be reported on as per your request?

The information specified in the request must be accurately reported on as per your request.

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