v6 © 07-2008	TERMINATE PATIENT THERAPY
Use your SHIFT LOCK * one patient per submission	Enter vital information to update
PROVIDER INFORMATION
Your Integrated Client Number or your name IMPORTANT: PLEASE - At Least Once Per Session of Claim Entry : YOUR EMAIL ADDRESS:
TERMINATION INFORMATION
. .       .Patient Name (last name first name mi) Effective Date (MM - DD - YY) .       . Reason to Terminate Billing the Patient Information :
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