dma-3350 Prior Approval Form for Lower Extremity Prosthetic Component L5781 or L5782
| Medicaid Form Number | dma-3350 |
| Agency/Division | Health Benefits/NC Medicaid (DHB) |
| Form Effective Date | 2015-09-20T13:15:00-04:00 |
| Form File | dma-3350.pdf |
| Medicaid Form Number | dma-3350 |
| Agency/Division | Health Benefits/NC Medicaid (DHB) |
| Form Effective Date | 2015-09-20T13:15:00-04:00 |
| Form File | dma-3350.pdf |