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Get FL Practitioner Disease Report Form 2014

64D-3, Florida Administrative Code (FAC). This can be filled in electronically. Patient Information SSN: MRN: Last name: Date onset: Date diagnosis: First name: Died: Yes No Unk Middle: Hospitalized: Yes No Unk Parent name: Gender: Print Form Medical Information Hospital name: Male Female Unk Pregnant: Ethnicity: Date admitted: American Indian/Alaska Native Asian/Pacific Islander Black Treated: White Other Unk Hispanic Non-Hispanic Unk No Unk No Unk Specify treatme.

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