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Transportation Details
Please fill in all hours and rate fields, even if the value is zero.
Date of Service
*
MM slash DD slash YYYY
ProCare's PO Number
Patient's Name
Service Type
Service Type
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Appointment Status
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Appointment Status*
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Start Time
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End Time
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Wait Time Hours
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Wait Time Rate
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Flat Rate
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Flat Rate Amount
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Total Mileage
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Per Mile Rate
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Other Quantity
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Other Rates
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Other Description
Other Description
Parking
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