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20232024 HEALTH ASSESSMENT Parts I TO BE COMPLETED BY PARENT/GUARDIAN13500 Lay hill Road, Silver Spring, MD 20906 3015762800 fax: 3015762805 Barrie.orchids Name (Last, First, Middle) Sex assigned
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Begin by providing your personal information such as name, date of birth, and contact information.
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Answer the demographic questions by providing details about your gender, race/ethnicity, and education level.
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Health Assessment Part I is a form used to assess the health insurance coverage of individuals and households, typically as part of compliance with health care regulations.
Individuals and families who are subject to health insurance mandates or specific regulatory requirements are required to file Health Assessment Part I.
To fill out Health Assessment Part I, review the instructions provided, gather required information such as personal and family data, and complete the form accurately before submitting it by the deadline.
The purpose of Health Assessment Part I is to determine compliance with health insurance coverage requirements and to ensure eligible individuals are enrolled in appropriate health plans.
Health Assessment Part I typically requires reporting personal identification details, insurance coverage information, and any exemptions claimed regarding health care mandates.
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2023 2024 barrie layhill tetenus childs birthdate covid prematurity anaphylaxis immunizations indemnify nebulizer hospitalization yr deafness applicable disabilities arising exemption uploaded palsy sickle endeavors willful meningitis exempt md misconduct

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