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Date of Completion: ___HIM ADVISORSINVESTMENTS and ADVICE for LIFE OF:(310) 4797958 / FAX:(310) 5825251 EMAIL: Dirk@HFMADV.comCONFIDENTIAL QUESTIONNAIRE CLIENT NAME (1):CLIENT NAME (2):Home Address:Home

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Home healthcare facility is a place where medical care and support is provided to individuals in their own residence.

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Information such as patient demographics, medical services provided, staff qualifications, and compliance with healthcare regulations must be reported on home healthcare facility.

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