NC DHHS FL2 2018-2024 free printable template
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Print Form Adult Care Home FL2 Form PRIOR APPROVAL UTILIZATION REVIEW ON-SITE REVIEW IDENTIFICATION 1. PATIENT S LAST NAME FIRST MIDDLE 5. COUNTY AND MEDICAID NUMBER 2. BIRTHDATE M/D/Y 6. FACILITY 3. SEX ADDRESS 8. ATTENDING PHYSICIAN NAME AND ADDRESS 11. RECOMMENDED LEVEL OF CARE 7. PROVIDER NUMBER 9. RELATIVE NAME AND ADDRESS 10. CURRENT LEVEL OF CARE 4. ADMISSION DATE CURRENT LOCATION HOME SNF ICF HOSPITAL DOMICILIARY REST HOME OTHER 14. DISCHARGE PLAN 13. DATE APPROVED/DENIED 15....
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