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Type in the essential details in I hereby certify that was, Name of Patient Name of Facility, for the primary presenting problem, I hereby certify that prior to, DATE Mo Day Yr SIGNED Receiving, RECEIVER CERTIFICATION, PRINTED NAME OF AUTHORIZED OFFICIAL, C AMBULANCE COMPANY CERTIFICATION, I certify that a reasonable, SIGNATURE OF AUTHORIZED OFFICIAL, D BUREAU OF COLLECTION SERVICES, Did patient have ability to pay at, and RECOMMENDED BY Name PRINT or TYPE area.
Remember to provide the required particulars in the RECOMMENDED BY Name PRINT or TYPE, and FIELD OFFICE DATE Mo Day Yr SIGNED field.
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