Common Contracts

1 similar Human Rabies Biologicals Payment Agreement contracts

HUMAN RABIES BIOLOGICALS PAYMENT AGREEMENT AND SURVEILLANCE REPORT (Version 12/10/10)
Human Rabies Biologicals Payment Agreement • January 3rd, 2011

To fully complete this form, the person distributing the biologicals should interview the patient or guardian. Additionally, a signature and other documentation must be obtained from the patient or guardian before the biologicals are distributed. The ordering physician’s UPIN/ NPI numbers are required when billing private insurance.

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