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TAX ID# 562629193Imaging RequisitionTodays Displease BRING THIS FORM, YOUR INSURANCE CARD AND PHOTO ID TO YOUR APPOINTMENTPatients Name: Appointment Date: DOB: Patients Daytime Phone: ICD10 Code/Clinical

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PDF section 5000child health is a section of a form or document that pertains to reporting information related to the health of children.

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Any individual or organization that has children under their care or responsibility may be required to file PDF section 5000child health.

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To fill out PDF section 5000child health, you will need to provide information about the health status, medical history, and any medical treatments of the children in your care.

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The purpose of PDF section 5000child health is to ensure that children receive appropriate medical care and treatment by recording and reporting relevant health information.

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