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Get La Dhh Oaas-pf-10-014 2014-2024

_______/Time:______________ AM or PM Type of Health Care Admissions and Date of Admissions (check all that apply): Psychiatric Hospital Date:___________ Acute Care Hospital Date:___________ Rehabilitation Facility Date:___________ Respite Center Date:___________ Emergency Room SS (Developmental Center) Date:___________ Date:___________ Nursing Home Date:___________ Hospice Date:___________ Reporter Name: Relationship: APS Friend/Neighbor Child Guardian Child Protection Home Health Curator Hospi.

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