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MEMBER CERTIFICATION OF MEDICAL NEED Note to Member: The Medical Providers portion of this form must be completed and signed by a licensed physician, physician assistant or advanced nurse practitioner.

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How to fill out the medical providers portion

01

Fill in the name of the medical provider.

02

Include the address of the medical provider.

03

Provide the phone number of the medical provider.

04

State the type of medical services offered by the provider.

Who needs the medical providers portion?

01

Individuals who have received medical treatment from a healthcare provider.

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What is the medical providers portion?

The medical providers portion is a section of a form where medical providers report information related to services provided.

Who is required to file the medical providers portion?

Medical providers who have provided services are required to file the medical providers portion.

How to fill out the medical providers portion?

The medical providers portion can be filled out by entering relevant information such as patient details, services provided, and billing information.

What is the purpose of the medical providers portion?

The purpose of the medical providers portion is to document and report the medical services provided by healthcare providers.

What information must be reported on the medical providers portion?

Information such as patient details, services provided, billing codes, and dates of service must be reported on the medical providers portion.

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