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Billing Application
TODAY'S DATE:
CLIENT'S NAME:
BILLING NAME, IF DIFFERENT THAN ABOVE:
SPECIALTY:
CONTACT PERSON:
CLIENT ADDRESS:
State
TELEPHONE NO.:
Fax NO.:
Fax NO.:
LICENSE NO.:
EMAIL ADDRESS:
MEDICARE PTAN:
MEDICAID NO.:
CLIA NO.:
RAILROAD NO.:
NPINO.: 1
NPINO.: 2
DOCTOR'S SIGNATURE:
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