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SECTION D PRESCRIBER S Attestation and Signature/Date I certify that I am the prescriber identified above. In Wt. PRESCRIBER NAME ADDRESS TELEPHONE - UPIN or NPI SECTION B Information in this Section May Not Be Completed by the Supplier of the Items/Supplies EST. I understand that any falsification omission or concealment of material fact may subject me to civil or criminal liability. STATE OF RHODE ISLAND EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES MEDICAID PROGRAM CERTIFICATE OF MEDICAL...
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