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Providers are anyone who performs CTR or medical evaluations for individuals diagnosed as having HIV and found to be positive. Person making referral other than provider Name Phone 15. Date of Referral Pregnant Not Applicable 8. Completion of this form does not replace the required submission of the HIV/AIDS Case Report DCH-1355 to report positive test results. Place of Employment 6. Sex at Birth Male Female Gender Identity Male Trans to Female 11 Referral Provider Name County 12. Date of...
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