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Dental CBCT Alternate QA Program
Dec 31, 2013 Training must be documented on the attached form, maintained in the facility file and made available upon the request of the Department. 2.
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CBCT Request Form
CONE-BEAM COMPUTED TOMOGRAPHY (CBCT) REQUEST FORM. FOR EXTERNAL REFERRING PRACTITIONERS. PATIENT INFORMATION. Name: Date of Birth: Gender: Mailing Address
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new york state medicaid program dental policy and
procedures, whether or not they require prior approval, must be listed and coded on the prior approval request form. Any completed treatment which is not
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