
Get the free Certifier's Worksheet for Completing the Birth ... - SD DOH
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Center for Advanced Maternal, Fetal & Newborn CarePERINATOLOGY CLINIC Provider Service Request Today's Date: Home Phone: Patient Name: DOB: Cell Phone: Provider Name/Clinic: Contact person at clinic:
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The information that must be reported on the certifiers worksheet includes personal identification details, income received, details of deductions or contributions, and any other specific financial figures required by the tax authority.
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