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The form was attempted to be signed by the patient but was not obtained for reasons listed.
Healthcare providers or medical professionals may be required to file this form.
The form should be filled out according to the instructions provided, including detailing the reasons for not obtaining the patient's signature.
The purpose of this form is to document the attempt made to obtain the patient's signature and the reasons for not being able to obtain it.
Information such as the date and time of the attempt, the identity of the person making the attempt, and the specific reasons for not obtaining the signature must be reported.
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