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Physician Order, Prescription, and Certificate of Medical Necessity for Lumbar Orthosis (LO) or Lumbar Sacral Orthosis (LSO) Date:_____ Patient Name
u.s. department of health & human services form approved health care financing administration omb no. 0938-0679 certificate of medical necessity dmerc 02.03b

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HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0679 CERTIFICATE ...

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u.s. department of health & human services form approved health care financing administration omb no. 0938-0679 certificate of medical necessity dmerc 02.03a

HEALTH CARE FINANCING ADMINISTRATION OMB NO. 0938-0679 CERTIFICATE ...

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Physician Order, Prescription, and Certificate of Medical ...
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