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Get Abreivement 2010-2024

Interest of your patient, please call the Access Center at 770-434-4568 ext 3200 to verify bed availability before faxing this information. Please note that we can accept this form only via fax. We cannot accept any electronic versions of this form sent via email or scanned and sent via email due to patient privacy concerns. REFERRAL SOURCE INFORMATION: (please provide your contact information here) REFERRAL SOURCE INFORMATION Name: Agency:.

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