
Sample bClaims Formb 2
1 3a pat. cntl # b. med. rec. # 2 longwood hospital 3290 albany ave kingston, ny 12401 8453402200 8 patient name 11 sex 09031980 31 occurrence code date b 12 f 100808 22 32 occurrence code date 2 1 09 18 100808 101108 25 market st c 19 7 statement...
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