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| Owner: | Division of Family Assistance |
| Effective Date: | 06/30/2009 |
| Client and Provider Instructions for Completion, and/or Processing of: Physician/Clinician Statement of Capabilities (Form 752), Physician/Clinician Statement of Necessary Patient Care for a Household Member (Form 752HH), Authorization for Release of Protected Health Information for the Use and Disclosure of Individually Identifiable Health Information (Form 752A) |
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