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PCC Credentialing ICP Reference Form Name of Applicant (Please print)Name of Reference (Please print)I (the applicant) waive the right to review reference responses to this form. DeSoto the Reference:

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Alcohol and drug abuse refers to the excessive and harmful consumption of substances such as alcohol and drugs.

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Information that must be reported on alcohol and drug abuse includes the demographics of individuals involved, the substances abused, the frequency of abuse, and any interventions or treatments provided.

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