| Prompt | Response | Req | Len |
|---|---|---|---|
| Code Category | Select the code category you want from the list. | 
|
1 |
| Certification Condition Indicator | If there is a certification condition, select this check box. |
1 | |
| Condition Code 1 | Select the condition code you want from the list. |
|
1 |
| Condition Codes 2 through 5 | Select the condition code you want from the list. | 1 |
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