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2024 NSW Speed State Team Medical Form (Please Print) Surname:___First Name:___D.O.B:___Medicare No: ___Emergency Contact Person Name:___Address:___Home Phone: ___ Mobile:Work Phone: ______Relationship

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State team medical amp refers to a reporting system for medical professionals and healthcare providers to submit claims and information related to medical services provided within a state.

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Information that must be reported includes patient demographics, service dates, procedure codes, billing amounts, and any other information mandated by state regulations.

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