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CHOCTAW NATION GAMING COMMISSIONSELFEXCLUSION FORMPlease Print Clearly:The CNGC will treat this SelfExclusion Form request confidentially.Full Name:___Date of Birth:I understand any identified selfexcluded
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01
Gather all necessary information about the patient's medical history and current condition.
02
Fill in the patient's personal information accurately on the form.
03
Provide detailed information about the symptoms or condition for which treatment is needed.
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Include any relevant medical test results or diagnostic reports.
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Specify any medications or allergies the patient may have.
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Sign and date the form before submitting it to the CNGC for treatment.

Who needs the cngc will treat?

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Patients who require specialized medical treatment from the CNGC.
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Patients who have been referred to the CNGC for specialized treatment options.
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