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Get AZ PM 7.3.1 2009-2024

One: Contact Person/Title: Name and Title of Person Authorizing the event: Name and Title of Person Re-authorizing the event: Reporting Information: Recipient Name: SS#: Age: Gender: Male Female CIS Identifier: Diagnoses: Medications: Recipient Behavioral Health Category: SMI Non-SMI SED Non-SED TXIX/XXI Eligible: Y N Date/Time of Evaluation/Assessment: Seclusion: Date Administered: Name/Title: Time: Duration of Seclusion: minutes/hours Mechanical Restraint: Date Administered: Na.

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