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Get Gateway Health Member Outreach Form 2018-2024

Guardian Name Relationship PCP Name Provider ID Number PCP Contact Person PCP Contact Phone Number Date of Birth Phone Number Date Sent to GHP Member is being referred for the following: (Gateway Health will call the member to educate, to assist with scheduling appointments and transportation as needed.) Referring Office Call Back Test Results (e.g. Elevated Lead Levels) Name: Date of last Draw: Phone Number: Result of last Draw: Date script was given for Blood Lead Level: Over d.

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