MEPS-MPC-Office Based

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PATIENT NAME:

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REPEATING IDENTICAL VISITS CONTINUATION SHEET
FOR
SEPARATELY BILLING DOCTORS FOR REFERENCE YEAR 2005

M:\7690\7690.19.04\MPC 2005\Forms\SBD\SBD B6c ContSheet.doc - 1/26/2006 - 12:02 PM - SH

B6c. Please tell me the dates of those other visits.

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M:\7690\7690.19.04\MPC 2005\Forms\SBD\SBD B6c ContSheet.doc
- 1/26/2006 ___/___20___
- 12:02 PM - SH
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OFFICE
USE
ONLY