Phone: 513-874-7171
Fax: 513-874-0018
4911 Mulhauser Road, Cincinnati, OH 45011
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Printed to Government Printing Office standards. OCR ink for scanning. American Medical Association (AMA) approved format.
Laser Printer Compatible. Form Type Details: UB04; Dated/Undated: Undated; Forms Per Page: 1; Form Size: 8.5 x 11.