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Ly to Inspect or Receive Copies of the following records (use additional sheets as needed and attach) NAME: PHONE: ( ) EMAIL: FIRM: ADDRESS: SIGNATURE: 2. DATE: TO THE APPLICANT: -Records Provided The reproduction costs for the records are $ . Please forward a check payable to the New York State Department of Health to the address listed above. If we do not receive your payment within 60 days, we will assume that you no longer wish to receive the materials, and they will be sent.

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