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Get OH INS 9028 2001-2023

Mber INS 9028 Rev. 2001 2 SECTION III OFFICE/PRACTICE INFORMATION Please include all offices/practices. Copy and complete this sheet for each additional office. Is this your primary office? Yes What type of care do you provide? No Primary Care Specialty Care Specialty: Type of Practice: Subspecialty: Solo Single Specialty Group Multi-specialty Group/Other Please list other members of your practice and their specialties. Please list the coverage arrangements for your office. Start.

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