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care service, (type of service) _________________________________________________, as a Telehealth service. I understand that the health care practitioner (name) ______________________________________________________ is located in another facility (facility name and address) ________________________________________________________________________________________________________. A Telehealth service means that my visit with a practitioner at the distant site will happen by using special audiovi.

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We have the aim of making it easier for every American to fill in and submit Form without unnecessary inconvenience or confusion. Viewing the video guide below can help you work through each step of the workflow.

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