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form m11q
form m11q

Fillable Human Resources Administration MEDICAL REQUEST ... - NYC . gov - nyc

Description

TELEPHONE NO. ZIP CODE Contact Person Contact Tel. No. II. MEDICAL STATUS PATIENT S MEDICAL RELEASE I hereby authorize all physicians and medical providers to release any information acquired in the course of my examination of treatment to the New York City HRA/ Dept. of Social Services in connection with my request for home care. SIGNATURE X Date of next examination Check DATE OF ONSET Anticipated Recovery 6...
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