BCBSHMO_FaxCoverSheet
1 min
3755 Admiral Drive Suite 106 High Point, NC 27265 P: 336-887-9460 F: 336-887-5710
Send to: BCBS HMO | From: Yolanda Keel |
|---|---|
Attention: Medical Determination Dept | Date: 5/1/17 |
Ref: | Office Location: 3755 Admiral Drive, Suite 106 |
Fax #: 336-794-1556 | Phone #: 336-887-9460 |
- Urgent
- Reply ASAP
- Please comment
X 4. Please review
- For your information
Total pages, including cover: __2_
Comments:
Dr. Clifton Mays, DC NPI: 1326035627 Tax ID: 455374100
Patient: Benny Clark Hedrick
DOB: 02-11-1947 ID#: YPWJ1247965101
Procedures: 97110, 97032, 97012, 97140, 97035
DX Code(s):
Effective Dates: 3/3/2017-12/31/2017