health services / medical care services / persons receiving services / /
Organization
Notary Public My commission / Department of Health / U.S. Citizenship and Immigration Service / Florida Department of Health Revised / U.S. Department of State / Medicare / /
FLORIDA FOREIGN PHYSICIAN WAIVER PROGRAM HEALTH AND HUMAN SERVICES VISITOR EXCHANGE -HHS AFFIDAVIT AND AGREEMENT FORM BEFORE ME, the undersigned authority, personally appeared as ,