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Get Ny Sdmc Form 220-a 2017-2024

Y: All Parts of this form must be completed. Please return to the provider agency so a completed packet can be submitted to SDMC. Type or print in black ink. Part 10 Attending Physician must complete, sign and date where indicated. Part 1. Is an Expedited Review necessary? YES This is defined as the proposed treatment is of an urgent need that is expected to be performed within 10 days. NO If YES, you must state the medical facts to support the request. Part 2. Patient Information Firs.

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