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Get Illinois Petitioner Treatment Verification

Attach to this Treatment Verification form a Comprehensive Discharge Summary and when applicable the treatment waiver as recommended in the TNA. PETITIONER INFORMATION Name Last First Middle Illinois Driver s License Number Address Street/City/State/ZIP Sex Date of Birth M F Home Telephone Number / Work Telephone Number Referral Source Admission Date Discharge Date Primary treatment only not follow-up/aftercare Admission Diagnosis Discharge Diagn.

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