Community Health Group | Add/Change Diagnosis Code

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Add/Change Diagnosis Code

Issue Statement:

Authorization #:

Member Name:

CHG ID #:

Add Diagnosis Code:

Multiple diagnosis codes will be separated by commas. The format will be "D60.1, D60.2, D60.3"

Change Diagnosis Code:

Multiple Diagnosis codes will be separated by commas. The format will be "D60.1 = D60.2, D60.2 = D60.3"

Name:

Phone #:

Email Address:

File(s):

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