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00 fee will be required prior to mailing. It is your responsibility to meet all requirements for EAP Authorizations as set forth in your EAP contract. You are required to keep three consecutive visits with your provider before we are able to complete any FMLA or Disability forms. Patient Name Today s Date Address City State Zip Home Phone Cell Phone Age Date of Birth Employer Occupation Marital Status Single Married Divorced Widowed Separated Engaged Living Together Spouse s Name Date of...
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Today's date is November 10, 2021.
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