Get the free Fax completed form to: (208) 302-0755 DIABETES EDUCATION ...

Fax completed form to: (208) 3020755 DIABETES EDUCATION REFERRAL Provider ___Date ___ Patient Name ___ Date of Birth ___/___/___ Address ___ Phone (h) ___City ___(w) ___State ___Gender/Flip ___(c)

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4. Double-check the information for accuracy and completeness.
5. If necessary, get any relevant signatures or authorizations on the form.
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