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PM FORM[removed]MEDICAL CARE EVALUATION (MCE) STUDY REQUEST FOR REGISTRATION White Mountain Apache TRBHA NAME OF FACILITY:
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Document Date: 2008-12-10 11:44:28

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City

AHCCCS PROVIDER / /

Facility

SMI LEVEL OF FACILITY / STUDY REQUEST FOR REGISTRATION White Mountain Apache TRBHA NAME OF FACILITY / Facility Approved / /

Organization

T/RBHA QM/UR Committee / /

Position

T/RBHA Medical Director / /