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Y treatment and meet the criterion for this medication. Complete Sections 1 through 4 of the form. Instructions for proper completion are on page 2 of this form. Send the completed form to the Division of Behavioral Health and Recovery (DBHR) by fax at 360-725-2279 for review. 1. CHEMICAL DEPENDENCY TREATMENT AGENCY SECTION NAME OF DBHR CERTIFIED CHEMICAL DEPENDENCY TREATMENT AGENCY AGENCY NUMBER (USE NUMBER IN DIRECTORY OF CERTIFIED CHEMICAL DEPENDENCY SERVICES IN WASHINGTON STATE ) 2.

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