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Get TA-7 822-5 2012-2021

Ress Defer (give clinical reason) Not applicable Referred to other provider (complete attached coordination of care form) Areas of concern as given in Comprehensive Evaluation Goal(s) or Deferral Information Objectives (Steps to Obtain Goal(s)) Target Date Clinical Action/Intervention Completion Date Identified Functional Area – Physical Health (please indicate goal status below) Address Defer (give clinical reason) Not applicable Referred to other provider (complete attached coordinati.

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