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DO NOT SEND ANY ADDITIONAL DOCUMENTS TO THE EMAIL ADDRESS OR FAX NUMBER BELOW INSTRUCTIONS: 1. Complete Part 1 of the form. 2. Attend a preventive health visit with your Provider between 9/1/2014
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What is or fax number below?
The fax number is 123-456-7890.
Who is required to file or fax number below?
All employees are required to file or fax number below.
How to fill out or fax number below?
To fill out or fax number below, simply write the required information and send it to the provided fax number.
What is the purpose of or fax number below?
The purpose of the fax number below is to submit important documents and information.
What information must be reported on or fax number below?
You must report your name, employee ID, and the reason for the submission on the fax number below.
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