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Get Ri Tdi Application 2012-2024

447 Tel.# for patients: 401-462-8420 FAX # (401) 462-8466 STATEMENT OF QUALIFIED HEALTHCARE PROVIDER (QHP) (Physician or Medical Practitioner) Printed from Website Treating Physician or Medical Practitioner’s Name: ___________________________________________ Treating Physician or Medical Practitioner’s Address: ___________________________________________ ___________________________________________ ___________________________________________ Claimant’s S.S. #: ________-________-________.

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