Nuclear medicine i-131 mibg treatment work-up sheet for residents/fellows resident/ fellow: referring physician: date: / / pager: dob / / patient name: height: weight: x-ray #: does not apply no yes on / pregnancy test (for all child-bearing age...
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(a) notifier(s): (b) patient name: (c) identification number: advance beneficiary notice of noncoverage (abn) note: if medicare doesn t pay for (d) below, you may have to pay. medicare does not pay for everything, even some care that you or your...
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De-131 attorney or party without attorney (name, state bar number, and address) : telephone and fax nos.: for court use only to keep other people from seeing what you entered on your form, please press the clear this form button at the end of the...
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North carolina department of the secretary of state charitable solicitation licensing division 131f-3(3) exemption request form ? 1. charitable/sponsor organization s legal name: 2. charitable/sponsor organization s principal mailing address: 3....
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Office use: application no application form personal account holders (local & overseas) please use block letters (01). title: rev. / dr. / mr. / mrs. / miss. date: dd / mm / y (02). name of applicant (with initials): (03). gender: male / female...
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