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APPLICATION FOR APPROVED PROVIDER OR AFFILIATE PROVIDER SEX OFFENDER OUTPATIENT SERVICES Name Date Agency/Clinic Affiliation if any Agency/business owner Address of Agency City State and Zip Email Phone Is applying for status indicated below as given recognition by the Utah Department of Corrections Check the one that applies Approved Provider Approved Affiliate Provider Approved Evaluator Emeritus Provider APPROVED PROVIDER APPLICANTS the following is required - Read and agree to the UDC...

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What is agencyclinicaffiliationifany?

Agency/Clinic Affiliation, if any, refers to any formal association or connection between an agency and a clinic.

Who is required to file agencyclinicaffiliationifany?

Healthcare providers or agencies that have a formal affiliation with a clinic are required to file the agency/clinic affiliation form.

How to fill out agencyclinicaffiliationifany?

The agency/clinic affiliation form can be filled out by providing details of the formal association between the agency and the clinic, including names, dates, and specific information about the nature of the affiliation.

What is the purpose of agencyclinicaffiliationifany?

The purpose of the agency/clinic affiliation form is to disclose any formal connections between healthcare agencies and clinics to ensure transparency and compliance with regulations.

What information must be reported on agencyclinicaffiliationifany?

The form must include details of the agency and clinic, dates of affiliation, nature of the connection, and any other relevant information.

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