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I authorize QIRN3 and my dialysis center if applicable to utilize my name and email address for specific PAC communications. I further authorize QIRN3 to use my name where necessary in PAC meeting minutes and in listing PAC members in reports to the Centers for Medicare and Medicaid Services CMS and other business documentation. Candidate s Signature Date Staff Signature Date Please submit via fax to Yessi Cubillo 609-490-0835 or postal service QIRN3 - 109 South Main St Suite 21 Cranbury NJ...
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