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Idalia Montanez Miranda PLLC
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First Name
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Last Name
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Street Address
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State
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Postal Code
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Date of Birth
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Requested Service
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Behavioral Health Intervention (BHI) - no mental health diagnosis
Psychological Therapy - when an allowed mental health diagnosis is already on the claim
Independent Psychological Evaluation
120-Day Independent Psychological Evaluation
Relationship to patient
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Self
Attorney
Vocational Rehabilitation Counselor
Case Manager
Mental Health Provider
Attending Physician
Availability for scheduling sessions
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Referring person
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Referring person's phone
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Referring person's email
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Claims manager name
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Claims manager's phone
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Claim Number
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Date of Injury
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Attending physician's name
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Attending physician's phone
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Attending physician's fax number
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Attorney's name
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Attorney's phone number
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