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Get Ny Doh-3608 2008-2024

Physician Signature MUST BE ACTUAL SIGNATURE DATE ON THE BACK OF THIS FORM PLEASE PROVIDE THE INFORMATION REQUESTED. IF YOU HAVE ANY QUESTIONS ABOUT MEDICAL ELIGIBILITY PLEASE CONTACT OUR TOLL FREE HOTLINE 1-800-542-2437. WHEN COMPLETED PLEASE RETURN TO EMPIRE STATION P. O. BOX 2052 ALBANY NY 12220-0052 DOH-3608 11/08 Page 1 of 2 MEDICAL INFORMATION Please Answer All Questions Patient s Name DOB SECTION I - DISEASE STAGING Is the applicant HIV in.

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