A
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B
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C
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D
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E
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F
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G
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H
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I
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J
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K
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L
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M
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N
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O
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P
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Q
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R
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S
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T
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U
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V
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W
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X
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Y
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Z
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OTHER
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Directory Results for (Employee Signature) (Date) (For Office Use Only) IN THIS PROCESS, PRIVACY CANNOT BE GUARANTEED Approved Not Approved (Director Signature) (Date) Revised 12/3/2012 jf PHYSICIAN/HEALTH CARE PRACTITIONER VERIFICATION to (Employee to Commissioner and to Employer)

(Employee Signature) (Date) (For Office Use Only) IN THIS PROCESS, PRIVACY CANNOT BE GUARANTEED Approved Not Approved (Director Signature) (Date) Revised 12/3/2012 jf PHYSICIAN/HEALTH CARE PRACTITIONER VERIFICATION
(Employee Street Address)
(employee title)
(Employee to Commissioner and to Employer)