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        Sports Reaction Center
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Physicians Profile Form

Referring physicians: Please fill out this form and click the "Submit" button below.

This information is required for us to bill the patient's insurance company.
Please refer to the Insurance Detail Information.

*Physician's Name:
*UPIN #:
*Medicare #:
*Practice Name:
*Practice Address:
*Address (continued):
*City:
*State:
*ZIP:
*Practice Phone Number:
*Practice Fax Number:
*Email Address:
*Date:
Any additional information:

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Physical Therapy | Sports Therapy | Rehabilitation Services | Orthotics | Occupational Therapy

Sports Reaction Center — Physical Therapy for Active People in Bellevue, WA
1750 112th Ave NE Suite D-154, Bellevue, Washington 98004 (425) 643-9778
Billing and Insurance Contact Numbers: (206) 542-7118 or (888) 637-0702

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Last Updated : 7/29/2010