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Of practice If other please explain Office Hospital Other Practice/Hospital Name Suite AHCP-IL-01 01/2014 E. Billing and Correspondence Address Location from Question D. A. What is your present specialty of total practice What is your sub-specialty B. Education/Training Name of School Credentials CRNA OD RN etc. Completed from MM To YYYY C. Casting and Splinting. Directly assisting as a non-physician first assistant in surgical procedures. Agent s Signature VII. Supplemental Information-The...

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