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Form #
CMS 1856
Form Title
Request for Certification in the Medicare and/or Medicaid Program to Provide Outpatient Physical Therapy and/or Speech Pathology Services
Revision Date
12/11/2006
O.M.B. #
0938-0065
O.M.B. Expiration Date
08/31/2014
CMS Manual
N/A
Special Instructions
N/A