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01 Inpatient Hospital Inpatient- Drug / Alcohol Treatment F01. 88 F01. 99 F02 Outpatient facility F02. DO NOT mark over area of the oval. HIV TEST FORM Code 128 PART 1 0000000000 Form Approved OMB No. 0920-0696 Exp. Date 08/31/2010 Agency Session Date MMDDYYYY Unique Agency ID Number Intervention ID MMDD Site ID. 06 Practice Providing prevention services F03 F04. 05 F06 F06. 02 F07 F88 Emergency Room Blood Bank Plasma Center HIV Counseling and Testing Site Community Setting Individual...
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