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Get AL PEEHIPSCR-HLTHCR PRVDR 2016-2024

0-252-1818 Fax: 1-334-206-0385 1-334-206-0394 HEALTHCARE PROVIDER SECTION 1: (To Be Completed by Active or Retired Employee or Spouse) Contract Number: PRINT CLEARLY WITH A BLACK INK PEN. SSN: (of person being screened) Screen Date: - DARKEN BOXES COMPLETELY. << This X << Not This << Not This Birth Date: - - - Male Contract Holder Female Spouse Daytime Phone Number: - Last Name: - - First Name: Screening not performed due to: Pregnancy What best describes your race/ethnic.

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