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LONG-TERM CARE POLICY Application to Physicians Mutual Insurance Company PO Box 2316 Omaha, Nebraska 68172 Policy Number SECTION A Applicant's Name (Please Print) (First) (Middle Initial) (Last) Street

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Index of formsltcphysiciansnj is a form used to report information about physician practices in long-term care facilities.

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Physicians who practice in long-term care facilities are required to file index of formsltcphysiciansnj.

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Information such as physician name, practice location, services provided, and patient demographics must be reported on index of formsltcphysiciansnj.

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