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Self Pay Formation Name: ENC#: Date: / / services PerformedServicePriceqUrgent Care Visit$125.00qPoint of Care (POC) Testing 50.00qXRay$ 50.00qEKG$ 50.00qProcedure*$75.00qImmunizationq TAPE 75.00

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What is mcuc self pay formdocx?

MCUC self pay formdocx is a form used by individuals to report and pay their utility charges directly to the utility provider.

Who is required to file mcuc self pay formdocx?

Individuals who directly pay their utility charges to the provider are required to file mcuc self pay formdocx.

How to fill out mcuc self pay formdocx?

MCUC self pay formdocx can be filled out by providing details of the utility charges paid, personal information, and payment details as required on the form.

What is the purpose of mcuc self pay formdocx?

The purpose of mcuc self pay formdocx is to ensure accurate reporting and payment of utility charges directly to the provider by individuals.

What information must be reported on mcuc self pay formdocx?

Information such as utility charges paid, personal details, and payment method must be reported on mcuc self pay formdocx.

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