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Primary Physician Number


This form contain medical information that is for sole use of the intended recipients. The information on this form is highly confidential and protected by both State and Federal Law. It is unlawful for unauthorized persons to review, copy, disclose, or disseminate confidential medical information. If the reader of this information is not the intended recipient of the form, or the intended recipient’s agent, you are hereby notified that you have received this form in error and that review or further disclosure of the information contained in this form is strictly prohibited. If you receive this form in error, please notify us immediately and destroy these documents. You can contact us at: (419) 222-9410 or fax (419) 222-6175 and destroy all copies of the original form or documents. Thank You