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PATIENT INFORMATION
MID
LAST NAME
FIRST NAME
DATE OF BIRTH
STREET
CITY AND ZIP
ADMIT DATE
SEX
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Male
Female
PHYSICIAN INFORMATION
ATTENDING NPI
ATTENDING PHYSICIAN
I confirm that this first name and surname are correct
CERTIFYING NPI
CERTIFYING PHYSICIAN
I confirm that this first name and surname are correct
DIAGNOSIS
PRIMARY RX
ADD RX
COMMENTS (OPTIONAL)
📃 Generate NOA-file