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Get NYC TB 354 2010-2024

Rm in entirety and fax to 347-396-7579 SECTION A: Patient Contact Information DOB: _______/_______/_______ Patient name: mm Tel. #: (1) ( ______ )_________ – ______________ dd yyyy (2) ( ______ )_________ – ______________ Address: Apt.: Emergency contact name: City: State: Zip: Tel. #: ( Relationship to patient: ) – SECTION B: Discharge Information Discharging facility tel. #: ( Discharging facility: Address: Fl.: Patient medical record #: Date of admission: City: mm.

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