1048 APS-A
Any charge for completing this form is the patient's responsibility. 1048 APS-A 11/ 05 continued on back. 1 Patient Authorization. Name. Date of birth
12 MONTH VISIT CHILD HEAL TH RECORD
PRIMARY CARE GIVER: PHONE: INFORMANT: 12 MONTH VISIT. CHILD HEAL. TH RECORD. HISTORY. See new patient history form. INTERVAL HISTORY:
Environmental Protection Agency § 1039.245
total hydrocarbon (THC) emissions. In- dicate in your application for certifi- cation if you are using this option. If you do, measure THC emissions
MMASC: LTD or STD Attending Physician Statement
Fax this form to expedite your claim - retain original for your records. Any fee for the completion of this form is the patient's responsibility. SCR