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Ould be completed by medical personnel, if applicable). Send to Centralized Intake via a method listed on page 2. If only reporting an infant was born exposed to alcohol, a controlled substance, or metabolite, administered to the infant or birthing parent because of medical treatment, notify the Centralized Intake hotline. Do not use the MDHHS-3200. SECTION 1 INTAKE INFORMATION 1. Date 2. Was this referral phoned to MDHHS? If yes, Intake Identification (ID) Number Yes No If no, contact Cent.

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