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MEDICAL SOURCE STATEMENT MENTAL (ADULT) IN THE MATTER OF: Claimant: ___; SSN: _________ FOR SSI AND/OR SDI BENEFITS Patient:___Address:___Physicians Name:Date of Birth:______Address:___Phone:___Fax:___From

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Obtain form HA 1152 medical from the appropriate authorities.

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Fill in all the required personal information such as name, date of birth, address, etc.

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Provide detailed information about your medical history and any current medical conditions.

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Individuals who are seeking medical assistance or benefits.

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What is form ha 1152 medical?

Form HA 1152 is a medical billing form used primarily for reporting healthcare-related services and expenses for the purpose of insurance claims.

Who is required to file form ha 1152 medical?

Healthcare providers who are seeking reimbursement from insurance companies for the medical services provided to patients are required to file Form HA 1152.

How to fill out form ha 1152 medical?

To fill out Form HA 1152, providers must enter the patient's personal information, details about the medical services provided, any applicable diagnosis codes, and the associated costs for the services rendered.

What is the purpose of form ha 1152 medical?

The purpose of Form HA 1152 is to facilitate the billing process for medical services and to ensure that healthcare providers are reimbursed by insurance companies for the services rendered to patients.

What information must be reported on form ha 1152 medical?

Information that must be reported on Form HA 1152 includes the patient's name, insurance details, service dates, description of services, diagnosis codes, procedure codes, and the total charges for the services.

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