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OUTPATIENT TREATMENT REQUEST (OR) Effective 01×01/2011 Instructions: Please print legibly in black ink. Fields in shaded areas are mandatory. Fax to BCB STX at 8773617646 Request ID #: Patient /
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This form is used for reporting clinical information.
Healthcare providers and staff involved in clinical data collection.
The form can be filled out electronically or manually, following the guidelines provided by the healthcare institution.
The purpose is to gather and report clinical data for analysis and research purposes.
Patient demographics, medical history, treatment details, and outcomes.
The deadline is typically at the end of the fiscal year, around December 31st.
Late filing may result in fines or other penalties imposed by regulatory authorities.
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