Case Manager and Adjuster Quick Referral

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Patient Information

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Service Detail

• Items / Service Requested Acupuncture Breast Pump Chiropractic Complex Rehab Dental Diabetic Diagnostic Imaging DME DME Supplies Flights and/or Lodging Hearing Home Health Home Infusion Home Modification Orthotics Physical Medicine Post Acute Cure Sleep Therapy Translation Services Transportation Vehicle Modification Wound Therapy
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• Referral Role Adjuster Attorney Case Manager Facility / Office Insurance Patient Peer Review Provider Referral Source
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File Attachment (Browse to attach a file to your order such as a prescription or other documentation.)

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