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Get Ma 34 2009-2024

__________________________________ CERTIFICACION DE GASTOS FIJOS POR MEDICAMENTOS AUTORIZACION DEL SOLICITANTE O RESOLICITANTE O PERSONA ENCARGADA Por la presente autorizo al Programa Medicaid del Departamento de Salud a que esta información sea comprobada con la fuente correspondiente. _______________________________ ____________________________________ (Testigo de la marca) (Firma del Paciente) _____________________________________________ (Fecha) CERTIFICACION DEL MEDICO CERTIFICACION .

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