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[PDF File]Patient Health Questionnaire (PHQ-9)
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PHQ-9 Patient Depression Questionnaire For initial diagnosis: 1. Patient completes PHQ-9 Quick Depression Assessment. 2. If there are at least 4 3s in the shaded section (including Questions #1 and #2), consider a depressive

[PDF File]Request for Social Security Earnings Information
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Form . SSA-7050-F4 (03-2019) Page 2 of 4. REQUEST FOR SOCIAL SECURITY EARNING INFORMATION . 1. Provide your name as it appears on your most recent Social Security card or the name of the individual whose

[PDF File]MEDICARE ENROLLMENT APPLICATION
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cms-855i see page 1 to determine if you are completing the correct application. see page 3 for information on where to mail this completed application. see section 12 for a list of supporting documentation to be submitted with this application. to view your current medicare enrollment record go to: https://pecos.cms.hhs.gov

[PDF File]Indiana Parenting Time Guidelines
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Indiana Parenting Time Guidelines and should be specific in their written agreement. 3. Presumption. There is a presumption that the Indiana Parenting Time Guidelines are applicable in all cases. Deviations from these Guidelines by either the parties or the cou rt that result in parenting time less than the minimum

[PDF File]Removal and/or Inspection of a Motor Vehicle at a VSF
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Removal and/or Inspection of a Motor Vehicle at a VSF This Form is Approved by the Texas Department of Licensing and Regulation This document affects your legal rights and may give others access to your motor vehicle.

[PDF File]DEVELOPMENTAL COUNSELING FORM - United States Army
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To assist leaders in conducting and recording counseling data pertaining to subordinates. The DoD Blanket Routine Uses set forth at the beginning of the Army's compilation of systems or records notices also apply to this system. Disclosure is voluntary. PART I - ADMINISTRATIVE DATA PART II - BACKGROUND INFORMATION. PART III - SUMMARY OF COUNSELING

[PDF File]8821 Tax Information Authorization OMB No. 1545-1165
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If the tax information authorization is for a specific use not recorded on CAF, check this box. See the instructions. If you check this box, skip lines 5 and 6 . . . . . .

[PDF File]AUTHORIZATION FOR DISCLOSURE OF MEDICAL OR DENTAL INFORMATION
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section i - patient data 1. name (last, first, middle initial) 2. date of birth (yyyymmdd) 3. social security number 4. period of treatment: from - to (yyyymmdd) 5. type of treatment (x one) outpatient inpatient both section ii - disclosure 6. i authorize a. name of person or organization to receive my medical information b.

[PDF File]REQUEST AND AUTHORITY FOR LEAVE
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[PDF File]Form W-9 (Rev. October 2018)
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Form W-9 (Rev. 10-2018) Page . 2 By signing the filled-out form, you: 1. Certify that the TIN you are giving is correct (or you are waiting for a

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