√100以上 emod oO 983544-Mod of origin
ADMINISTRATIVE DIRECTIVE Transmittal 21ADM04 To Executive Directors of Voluntary Provider Agencies Executive Directors of Agencies Authorized to Provide Fiscal Intermediary Services Developmental Disabilities Regional Office and State Operations Office DirectorsPO Box FAX Yes No Albuquerque, NM Print Member/Participant Name Member/Participant Medicaid Card Number Approved Budget Period Waiver Service Procedure Code/Modifier Describe Item Being Purchased Full Payment Amount (including all taxes) Is the item being purchased an EMOD?Emod CV5WR E CV4W D CV3W C CV2W B CV1W REQUIREMENTS TYPICAL SIGN and sheeting as the parent sign attached above the parent sign shall be made with the same substrate signs shall be any material that meets DMS7110 Exit Number Panels of DMS7110 or approved alternative Sign substrate for overhead Mod O Sublime Original Mod of origin