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Method of Service Person or firm served I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct. at Type or print name Signature California. For Use with the QME Panel Request Form 106a MD/DO SPECIALTY CODES NON-MD/DO SPECIALTY CODES MAI Allergy and Immunology ACA Acupuncture MDE Dermatology DCH Chiropractic MEM Emergency Medicine DEN Dentistry MFP Family Practice OPT Optometry MPM Gener.

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