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CLIENT INTERVIEW INSTRUMENT (CII) ACCESS LOG (for HHS BBQ USE ONLY) NameDateCLIENT NAME: SAMPLE CATEGORY: MHC STAFF NAME: STAFF POSITION: MHC: PERIOD UNDER REVIEW: INTERVIEW COMPLETED BY:PURPOSEtoDATE(S)
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The New Hampshire Department of Health and Human Services.
Certain healthcare providers and facilities in New Hampshire.
Providers can fill out the form online or submit it via mail.
To collect information about healthcare services provided in New Hampshire.
Details of healthcare services provided, patient demographics, and billing information.
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