SAMPL E - CMS
EPSDT Family Plan ID. QUAL. NPI NPI ( ) PLEASE PRINT OR TYPE QUAL. QUAL. R svd for N UC e A. E. I. B. F. J. C. G. K. D. L. H. ICD Ind. IL L N E S S , IN JU R Y o r P R E G N A N C Y (L M P ) (N U C C ) co m p le te ite m s 9 , 9 a a n d 9 d 0 2 /1 2 O T H E R
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