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Get LA Standardized Cerdentialing Application 2012

Yes No Yes No Restroom: Yes No Other: Offers services for the disabled: Text Telephony (TTY): Yes No American Sign Language: Yes No Mental/Physical Impairment Services: Yes No Other: Does the office meet the Americans with Disabilities Act (ADA) accessibility requirements? Emergency After Hours Number Yes No Arrangements for 24 hour / 7 day a week coverage (Specify) Group, Covering or Collaborating Physician(s): Contact Name: Contact Phone Number.

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