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Get VT Health Care Professional Verification Form 2017

Ont 05671-1300 www.dps.vermont.gov  Department of Public Safety [phone] [fax] [email] 802-241-5115 802-241-5230 DPS.MJRegistry@vermont.gov HEALTH CARE PROFESSIONAL VERIFICATION FORM INSTRUCTIONS: This form must be completed by the patient applicant’s health care professional and signed within the last 6 months. This form and a Registered Patient Application MUST be completed and submitted for initial and renewal applicants. The definitions below are provided to assist health care professio.

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