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Get FL Practitioner Disease Report Form 2016-2024

64D-3.029, Florida Administrative Code, promulgated October 20, 2016 (laboratory reporting requirements differ). Patient Information Medical Information SSN: MRN: Last name: Date onset: Date diagnosis: First name: Died: Yes No Unknown Middle: Hospitalized: Yes No Unknown Parent name: Gender: Hospital name: Male Female Unknown If female, pregnant: Birth date: Race: Ethnicity: Yes No Unknown Laboratory testing: No Unknown Yes No Unknown Attach laboratory result(s) if.

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