If more space is needed attach additional sheets. Please include 1. Condition and diagnosis at the time of incident 2. Dates and description of treatment rendered and 3. Condition of patient subsequent to treatment. SUMMARY I certify that the information in this document and any attached documents is true and correct. I agree that this Healthcare Organization its representatives and any individuals or entities providing information to this Healthcare Organization in good faith shall not be...
california participating practitioner application addendum b

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