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REQUEST FOR AMENDMENT OF HEALTH INFORMATION Please complete the following information: 1. Today's Date: ___ 2. Patients Full Name: ___ 3. Birth Date: ___ 4. Patient #: ___ 5. Patient Street Address:
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The purpose of exhibit A-34 is to ensure transparency, compliance, and accountability by reporting specific information in a standardized manner.
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Information such as financial data, operational details, or any other data as required by the regulatory authority must be reported on exhibit A-34.
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