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STAT REFERRALRHEUMATOLOGY ORDER FORM
PATIENT INFORMATION
Last Name: ___ First Name: ___ MI___ DOB:___
HT: ___ in WT: ___ kg Birth Sex :() Male () FemaleAllergies: () NKDA, (Or):______
Provider Name___
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HIPAA stands for Health Insurance Portability and Accountability Act. It is a law designed to protect the privacy and security of patients' medical information.
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