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Physician s Signature Date ATTN Constantina Michalopoulos 6701 Fannin St. CC 1120 Houston Texas 77030 Phone 832-822-3620 Fax 832-825-3902. Child s name CSHCN DOB Parent/Guardian Name Primary Language Phone Other or E-mail Height cm Weight kg Address Condition/Diagnosis Allergies Exercise Concerns/Precautions Developmental Consideration Equipment Needs Medication Needs parent administered Physicians Name Phone Number Fax Number This child qualifies as a CSHCN. I know of no other health...
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03
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04
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05
Ensure that the form is filled out at least 2 days before the start date mentioned on the form.
06
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07
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08
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What is allinformationmustbecompletedampampfaxedatleast2daysbeforeformstartdateofform?
All information must be completed and faxed at least 2 days before the start date of the form.
Who is required to file allinformationmustbecompletedampampfaxedatleast2daysbeforeformstartdateofform?
The individual or entity responsible for the form is required to file all information.
How to fill out allinformationmustbecompletedampampfaxedatleast2daysbeforeformstartdateofform?
You can fill out all information required and fax it at least 2 days before the start date of the form.
What is the purpose of allinformationmustbecompletedampampfaxedatleast2daysbeforeformstartdateofform?
The purpose is to ensure that all necessary information is completed and submitted in a timely manner before the start date of the form.
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All relevant information related to the form must be reported.
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