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Authorization for Examination U.S. Department of Labor And ...

OWCP-04 or the UB-04). Physician services must be itemized by Current Procedural Terminology Code (CPT) using current CPT-4 coding schema; or, the UB-04 and the coding schemas acceptable on this form. For sale by the Superintendent of Documents, U.S. Government Printing Office, Washington, D.C. 20402. 27. Date(s) of Treatment (mo., day, …

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