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Get CA Provider Declaration of Compliance 2007-2024

Urth Floor San Francisco, CA 94103 Phn: 255-3758 Fax: 252-3001 PROVIDER DECLARATION OF COMPLIANCE Program/Contract Name: Legal Entity Name: Program Address: Provider Number: Program Manager Name: Program Director Name: Please put your initials on the line next to each applicable item for which this program is in compliance. Write N/A next to each item that is “Not Applicable” to this program/contract. Items applicable to only specific services are identified next to the item in the lis.

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