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EmblemHealth Benefit Extensions Treatment Plan
To be completed by the provider rendering therapy. Please print clearly or type, and complete the entire form.
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physical therapy medical history form
Past Medical History: Have you ever had any of the following conditions? Check all that apply. □High blood pressure. □Heart condition.
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Medical and Billing Form Updates/Clarifications (8/1/24)
On July 1, 2022, all medical providers will be required to use the CMS-1500 form with an attached medical narrative report to be considered a valid submission.
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