
ub 04 form
1 3a pat. cntl # b. med. rec. # 2 your agency name address city, st zip 9 patient address a aloha, john b 10 birthdate 11 sex 07/07/1957 12 12/24/2007 m 3 a 32 occurrence code date 33 occurrence date code 11 11 a3 12/24/2007 01/18/2008 19 20 34...
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