Guarantees that a business meets BBB accreditation standards in the US and Canada. Now you can print, download, or share the document. Use professional pre-built templates to fill in and sign documents online faster. Forms - School Health Program. PHYSICAL EXAMINATION FORM Name Last First Middle . The National Collegiate Athletic Association (NCAA) is a nonprofit organization that Use professional pre-built templates to fill in and sign documents online faster. 4 0 obj The Illinois Department of Public Health (IDPH) has developed rules to address this amendment, which have been adopted by the Joint Committee on Administrative Rules and are now a part of the administrative code. Complete Illinois Sports Physical Form 2020 in a few clicks by using the instructions listed below: Find the document template you will need from the collection of legal form samples. be ready to get more PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA . If conditions arise after the athlete has been cleared for participation, the physician may rescind the medical eligibility until the problem is resolved PHYSICAL EXAMINATION REQUIREMENTS Entire section below to be completed by MD/DO/APN/PA . Decide on what kind of eSignature to create. Health Centers can provide you and your family with comprehensive, culturally competent, high-quality primary health care services as well as supportive services such as health education, translation, and transportation that promote access to health care. There are three variants; a typed, drawn or uploaded signature. Therefore, the signNow web application is a must-have for completing and signing illinois physical exam form 2022 on the go. Install the signNow application on your iOS device. The required form is the Certificate of Child Health Examination provided by IDPH. 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We use cookies to improve security, personalize the user experience, enhance our marketing activities (including cooperating with our 3rd party partners) and for other business use. Mobile devices like smartphones and tablets are in fact a ready business alternative to desktop and laptop computers. Theft, Personal Refer to Section 664.120 of the Administrative Code for these requirements. Illinois Elementary School Association 1015 Maple Hill Road, Bloomington, IL 61705 PH . We make that achievable by giving you access to our feature-rich editor capable of changing/fixing a document?s original text, adding unique fields, and putting your signature on. Forms 10/10, Features Set 10/10, Ease of Use 10/10, Customer Service 10/10. Easily find the app in the Play Market and install it for signing your illinois physical exam form 2022. Your information is well-protected, since we keep to the most up-to-date security requirements. Enter your official identification and contact details. IDPH will also review available literature to determine whether there are peer-reviewed studies showing evidence that the tool is not valid for the ages, screenings, and populations proposed. The minimum interval or age. Bring these forms to your health care provider and return them to your school. Find the extension in the Web Store and push, Click on the link to the document you want to design and select. 050216.pdf Link to School Health Exam Form: . * Forms with an asterisk may be filled out on your computer, Cubby Hole Apparel Pre-Order Instructions, Cubby Hole Online Store Fall Sports Flyer Enjoy smart fillable fields and interactivity. It is imperative for parents and caregivers to submit health forms for students as soon as possible so they receive much needed health services. If you do not have Adobe Acrobat Reader on your computer, it can be downloaded directly from Adobe's web site, without charge, by clicking the button to the right. Service, Contact 1-2-90. The health and safety of your children is always our top priority, especially during a public health emergency. Find details about these requirements in the below forms. Test results _____ The School Health Program monitors 66 certified school health centers operating in Illinois for compliance with Title 77, Chapter V: Subchapter J, School-Based/Linked Health Centers Part 2200. Technology, Power of Decide on what kind of signature to create. All you need is smooth internet connection and a device to work on. See link to the Standards and list of sites and maps in the resource list. After that, your Illinois school physical form is ready. In Illinois, certain students must receive a physical exam and immunizations. Get connected to a strong internet connection and start completing documents with a court-admissible signature within minutes. Open the email you received with the documents that need signing. The signNow application is equally efficient and powerful as the online solution is. Athletic Training-Athlete Forms | Illinois Wesleyan. ' ""?f&24:0C5nR>dx$=4Ft)c$e$OMwYH0_\8 #I}_c|)n$R xBh>'.z:"^;6,gGz@,&U$xzlOSdgv#U0^[|O4|_Y3rj"TA=X@YVO>[-}ClA-M 6BQ9+7Asf. To find it, go to the App Store and type signNow in the search field. IHSA Steroid Testing Policy Consent to Random Testing (This section for high school students only) 2013-2014 school term CPS staff will review the forms and may contact the medical provider to clarify services required during school hours. This page contains links to numerous downloadable Microsoft Power Point presentations for the use of IHSA member schools. Select the area where you want to insert your signature and then draw it in the popup window. (2022-2023), W-9 Request for Taxpayer ID Number and Certification Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MB (html), Illinois Voter Registration Application SBE R-19 (pdf), Illinois Voter Registration Application SBE R-19 (Spanish) (pdf), Provider Forms Request (Springfield) HFS 1517 (pdf), Child Support Services Brochure Alphabetical Listing, Child Support Services Brochure Numerical Listing, Medical Program Brochures Alphabetical Listing, Medical Program Brochures Numerical Listing, Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP)IL 444-2378B (pdf), Request for Cash Assistance - Medical Assistance - Supplemental Nutrition Assistance Program (SNAP) IL 444-2378BS(Spanish) (pdf), Integrated Eligibility System (IES) Access Request HFS 1706G (pdf). Date of test results _____ . Go to the Chrome Web Store and add the signNow extension to your browser. %PDF-1.5 Find the extension in the Web Store and push, Click on the link to the document you want to design and select. Author: IHSA 1 0 obj * * *. If you encounter an error message, please contact our webmaster. endobj *effective January 2003, the IHSA Board of Directors approved a recommendation, consistent with the Illinois School Code, that allows Physician's Assistants or Advanced Nurse Practitioners to sign off on physicals. Download the Student Health Form booklet and vision or dental consent forms here. Therefore, signNow offers a separate application for mobiles working on Android. If you use Chrome or other browsers, you may experience technical difficulties with certain fillable PDF's, depending on your browser settings. Each child may present proof of having been screened to the local school authority in accordance with Section 27-8.1(2.5) of the School Code before October 15 of the school year in which screening is required. Additionally, a system to review and post age-appropriate, validated developmental and socio-emotional screening tools for use by qualified school support personnel and health care providers is being developed. The following forms allow students to receive their medication under adult supervision at school. Author: Nurse Created Date: 4/21/2022 10:48:35 AM . Create your eSignature, and apply it to the page. By signing these documents, you certify that you are authorized to complete the documents, and the information provided is true and accurate. Recipe Form - Navarro County Extension Office - Navarro Agrilife, Identity (2022-2023), Human Kinetics Coach Education ", To save images, click the thumbnail to open high resolution logo, right click and choose "Save Image As.". All students receiving physical or occupational therapy services are requested to provide a completed form signed by their medical provider each school year. 42 W. Madison StreetChicago, IL 60602773-553-1000, 2023 Chicago Public Schools | 1.0.8446 | VR, Close College and Career Planning (Grades 6-12) Subnav, Close Local School Councils (LSCs) Subnav, State of Illinois Vision Examination Report, College and Career Planning (Grades 6-12), Family and Community Engagement (FACE) Managers, Proposed Policies or Rule Changes Open for Public Comment, Reporting Harassment, Misconduct, or Abuse, CFBU: Connecting Families to Medicaid and SNAP, Office of Diverse Learner Supports and Services, contact your Network's Children and Family Benefits Coordinator, 2022-2023 OSHW Student Health Forms Booklet [, SY22-2023 Student Medical Information Form [, Illinois Certificate of Child Health Examination [, Physician's Report on Student with Major Health Problem (Major Medical PHC 60) [, Homebound Services (Referral for Adjustment of Educational Program) [, Consent for Release/Exchange of Student Records and Information [, Physician Request for Self-Administration of Medication [, Parent Request for Self-Administration of Medication [, Physician Request for Administration of Medication [, Parent Request for Administration of Medication to a Student [, Early Childhood Health Requirements (Ages 3-5) [, Physician Report on Child with Allergies [, Physician Statement for Food Substitution [, Physician's Request for Student to Carry an EpiPen [, Physician's Report of Child with Cardiac Condition [, State of Illinois Proof of Dental Examination Form [, Physician Report on Child with Diabetes [, Physician's Referral for Physical or Occupational Therapy [, Physician Report on Child with a Neurological Disorder [, Sports Physical - Pre-participation Examination [. Documenting your students asthma at school ensures proper support is provided for your student. <> With our solution completing Illinois Sports Physical Form 2020 will take a couple of minutes. Open the doc and select the page that needs to be signed. Choose the correct version of the editable PDF form from the list and get started filling it out. Handbook, DUI Persons administering screenings in schools shall minimally be: Refer to Section 664.110 of the Administrative Code for these requirements. Any child health exam that occurs after January 1, 2023 for the school year of 2023-2024, will need to utilize the updated child health exam form. examination findings are on record in my office and can be made available to the school at the request of the parents. Illinois Department on Aging (IDoA) Notification HFS 2538B (pdf) Illinois Department on Aging (IDoA) Notification HFS 2538BS (Spanish) (pdf) Illinois Early Intervention Program Referral Fax Back Form HFS 652 (pdf) Illinois Voter Registration Application SBE R-19 (pdf) Illinois Voter Registration Application SBE R-19 (Spanish) (pdf) Business. USLegal has been awarded the TopTenREVIEWS Gold Award 9 years in a row as the most comprehensive and helpful online legal forms services on the market today. TopTenReviews wrote "there is such an extensive range of documents covering so many topics that it is unlikely you would need to look anywhere else". <> signNow combines ease of use, affordability and security in one online tool, all without forcing extra DDD on you. immunization, form, health, exam, examination, school, 11/15 Created Date: 11/24/2015 8:38:41 AM . Get access to thousands of forms. If a specific vaccine is medically contraindicated, a separate written statement must be School Administration Directory Physical Exam / Medical History Forms The most frequently requested and downloaded form is the Student-Athlete Physical Exam / Medical History Form. signNow makes signing easier and more convenient since it provides users with a range of extra features like Merge Documents, Invite to Sign, Add Fields, etc. The signNow extension gives you a variety of features (merging PDFs, adding multiple signers, and many others) to guarantee a better signing experience. Attorney, Terms of Upload the illinois school physical form Edit & sign illinois physical exam form from anywhere Save your changes and share school physical form illinois Rate the illinois sports physical form 2022 pdf 4.8 Satisfied 3122 votes be ready to get more Create this form in 5 minutes or less Get Form Despite iPhones being very popular among mobile users, the market share of Android gadgets is much bigger. Illinois School Physical Form (Spanish) child health exam form spanish 11_15.pdf, 355.891 KB; (Last Modified on June 27, 2017) Darien School District #61. Screenings are to be done in conjunction with the school physical form and the child health examination within one year prior to entering kindergarten or the first grade of any public, private, or parochial elementary school; upon entering the sixth and ninth grades of any public, private, or parochial school; prior to entrance into any public, private, or parochial preschool; and, irrespective of grade, immediately prior to or upon entrance into any public, private, or parochial school or preschool. 191 0 obj <>stream Each local community decides which other services (i.e., drug and substance abuse counseling, mental health counseling, dental services, and family planning) will be provided on site or by referral. Important State of Illinois Health Requirements for the 2021-2022 School Year Physical examination and immunizations requirements MUST be on file prior to . An out of state health exam that is comparable to the Illinois Health Examination requirements, may be accepted at the time of first entry into an Illinois school. * Important Note: For best results, use Internet Explorer v11 or aboveto open HFS Medical forms. Services provided on site include: routine medical care for acute illness and injury, school/sports physicals, immunizations, nutrition counseling, sexually transmitted disease testing and treatment, pregnancy testing and health education. Application for Health Coverage and Help Paying Costs HFS 2378ABE (pdf), Application for Health Coverage and Help Paying Costs HFS 2378ABES (Spanish) (pdf), Mail-in Application for Medical BenefitsHFS 2378H (pdf), Mail-in Application for MedicalBenefitsHFS 2378HS (Spanish) (pdf), Approved Representative Consent Form IL 444-2998 (pdf), Approved Representative Consent Form IL 444-2998S (Spanish) (pdf), Personal Representative Designation HFS 3806F (pdf), Additional Financial Information for Long Term Care Applicants HFS 3654(pdf), Additional Financial Information for Long Term Care Applicants HFS 3654S(pdf), Application for Hardship Waiver of a Penalty Period HFS 2378WA (pdf), Application for Hardship Waiver of a Penalty PeriodHF S2378WAS (Spanish) (pdf), Statement of Hardship - Request for Waiver of Penalty Period HFS 2379WAS (Spanish) (pdf), Client/applicant Discrimination Claim HFS 185 (pdf), Abortion Payment Application HFS 2390 (pdf), Abortion Payment Application HFS 2390S (Spanish) (pdf), Additional Financial Information for Long Term Care Applicants HFS 3654S (Spanish)(pdf), ACH Direct debit Form for Hospital Assesments and GEMT HFS 3848G (pdf), Acknowledgement of Receipt of Hysterectomy Information HFS 1977 (pdf), Acknowledgement of Receipt of Hysterectomy Information HFS 1977S (Spanish)(pdf), Adaptive Behavior Support ServicePrior Authorization Form (pdf), Adjustment Form (Hospital) HFS 2249 (pdf), Advance Practice Nurse (APN) Certification and Collaborative Agreement Form HFS 3411C (pdf), Agreement for Participation in the Illinois Medical Assistance Program HFS 1413 (pdf), Agreement for Participation in the Illinois Medical Assistance ProgramHFS 1413S (Spanish) (pdf), Air Fluidized Bed Questionnaire HFS 2305A (pdf), Appendix E-3b Binaural Hearing Aid Questionnaire HFS 3701I (pdf), Application for Benefits Eligibility (ABE) (pdf), Application for Payment of Medicare Premiums, Deductibles and Coinsurance HFS 2378M (pdf), Application for Payment of Medicare Premiums, Deductibles and Coinsurance Spanish HFS 2378MS (pdf), Augmentative Communication Systems Assessment Review Checklist HFS 3640 (pdf), Augmentative Communication Systems Client Assessment Report HFS 3641 (pdf), Certificate of Medical Necessity for Continuation of External Insulin Infusion Pump Rental HFS 2305D (pdf), Certificate of Medical Necessity for External Insulin Infusion PumpHFS 2305F (pdf), Certification and Attestation for Primary Care Rate Increase HFS 2352 (pdf), Citizenship Documents and Your Medical Benefits HFS 3859D (pdf), Citizenship Documents and Your Medical Benefits HFS 3859DS(Spanish) (pdf), Compliance Report for Skilled Nursing HFS 2022 (pdf), Compression/Burn Garments Questionnaire HFS 2305K (pdf), C-PAP/BiPAP Renewal Questionnaire HFS 3701F (pdf), Gender-Affirming ServicesPrior Authorization Form(pdf), Health Agency Invoice Example Only HFS 2212(OCR)(pdf), Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MB (html)(pdf), Health Benefits for Workers with Disabilities (HBWD) Application HFS 2378MBS (pdf), Health Insurance Claim Form Example Only HFS 2360 (OCR) (pdf), Hospital Bed Questionnaire HFS 3905 (pdf), Hospital, Professional School or Group Practice as Alternate PayeeHFS 2307 (pdf), How to Get a Medical Card and a Primary Care Provider (PCP) for Your Baby HFS 4691 (pdf), Illinois Department on Aging (IDoA) Notification HFS 2538B (pdf), Illinois Department on Aging (IDoA) Notification HFS 2538BS (Spanish)(pdf), Illinois Early Intervention Program Referral Fax Back Form HFS 652 (pdf), Interagency Certification of Screening Results HFS 2536 (pdf), Involuntary Discharge Notice of Appeal and Request for Hearing HFS 3732 (pdf), Laboratory / Portable X-Ray Invoice Example Only HFS 2211 (OCR) (pdf), Long Term Care (SNF/ICF) Provider Monthly Assessment Report HFS 1446 (pdf), Long Term Care Bed Reserve/Temporary Absence Form HFS 2234 (pdf), Long Term Care Facility Notification HFS 1156 (pdf), Long Term Care Facility Third Party Liability (TPL) Payment Transmittal HFS 3461 (pdf), Long Term Care Provider Agreement Nursing Facilities and ICF/IID (Provider Types 33 and 29) HFS 1432 (pdf), Long Term Care Provider Agreement Supportive Living Facility (Provider Type 28) HFS 1432B (pdf), Long Term Care Provider Agreement State-Operated Facility (Provider Type 34) HFS 1433 (pdf), MCH Primary Care Provider Agreement HFS 3411A (pdf), Medicaid Payment of Medicare Cost Sharing Expenses HFS 3120(pdf), Medicaid Payment of Medicare Cost Sharing Expenses HFS 3120S (Spanish) (pdf), Medical Equipment /Supplies InvoiceExample Only HFS 2210 (OCR) (pdf), Medicar/Service Car/Taxicab Uniform Trip Ticket HFS 3825 (pdf), Medicare Crossover Invoice Example Only HFS 3797 (OCR)(pdf), Medicare Savings for Qualified BeneficiariesBrochureHFS 3757 (pdf), Medicare Savings for Qualified Beneficiaries Brochure HFS 3757(Spanish) (pdf), Motorized Wheelchair Evaluation Form HFS 3867 (pdf), NIPS AdjustmentForm (NIPS) HFS 2292 (pdf), Non-emergency Transportation Fingerprint Form HFS 3819 (pdf), Notice of DHS Community Based Services HFS 2653 (pdf), Notification to HFS of Illinois Medicaid Hospice Benefit Election HFS 1592 (pdf), Nursing Assistant Training and Competency Evaluation Reimbursement Request HFS 2310 (pdf), Nursing Facility Traumatic Brain Injury (TBI) Notification HFS 1435 (pdf), Nursing Facility Ventilator Notification HFS 106 (pdf), Optical Prescription Order HFS 2803 (OCR) (OCR), UB-04 Override Request Form HFS 1624A (pdf), Payment Review Request Form (LTC) HFS 3725 (pdf), Payment to Corporate Owner/Assurances HFS 2314 (pdf), Pharmacy Prior Authorization Request HFS 1409X (pdf), Power Mobility Devices and Custom Wheelchair Request Instructions forHFS 3701K (pdf), Preconception Screening Checklist HFS 27(pdf), Primary Care Provider Authorization (Non-Emergency Services Only) HFS 1662 (pdf), Prior Approval Request Instructions for HFS 1409 HFS 1409i (pdf), Progress Reportfor Negative PressureWound TherapyHFS 3785A (pdf), Provider Enrollment Application in the Medical Assistance ProgramHFS 2243 (pdf), Provider Enrollment Application Instructions for HFS 2243 (pdf), Provider Forms Request (Springfield) HFS 1517 (pdf)orOnline Form Request, Provider Invoice Example Only HFS 1443 (OCR)(pdf), Questionnaire andOrder for Cranial Remolding Orthosis or Cranial Cervical Orthosis Congenital Torticollis Type HFS 2305E (pdf), Questionnaire and Order for Neuromuscular Electrical Stimulator (NMES) HFS 2305I (pdf), Questionnaire for Airway Clearance Device HFS 2305B (pdf), Questionnaire for Continued Rental of Airway Clearance Device HFS 2305C (pdf), Questionnaire for Enteral Nutrition HFS 3701N (pdf), Questionnaire for Food Thickeners HFS 3701M (pdf), Questionnaire for Home Apnea Monitor HFS 2305G (pdf), Questionnaire for Home Phototherapy HFS 2305H (pdf), Questionnaire for Negative Pressure Wound TherapyHFS 3785 (pdf), Questionnaire for Orthosis HFS 2305N (pdf), Questionnaire for Prosthesis HFS 2305J (pdf), Questionnaire for TENS Unit HFS 3701E (pdf), Refill Too Soon Prior Approval Worksheet HFS 3082A (pdf), Report on Resident of Private Long Term Care Faciltiy HFS 26 (pdf), Request for Drug Prior Approval Form HFS 3082 (pdf), Request for Extended Sass Services Form HFS 3833 (pdf), Request For Inappropriate Level Of Care Payment HFS 3127 (pdf), Screening Verification Form HFS 3864 (pdf), Screening, Assessment and Evaluation Tool Approval Request Form HFS 724 (pdf), Seating/Mobility Evaluation (pdf) HFS 3701H, Seating/Mobility Evaluation Instruction for HFS 3701H (pdf), Supportive Living Program Notice of Involuntary Discharge HFS 3731 (pdf), Special Decubitus Mattress Questionnaire HFS 3701G (pdf), Standard Manual Wheelchair Questionnaire HFS 3701L (pdf), Standardized Illinois Early Intervention Referral Form HFS 650 (pdf), Statement of Good Faith Effort HFS 3859B (pdf), Statement of Good Faith Effort HFS 3859BS (Spanish) (pdf), Statement of Hardship - Request for Waiver of Penalty Period HFS 2379WA (pdf), Statement of Hardship - Request for Waiver of Penalty Period (Spanish) (pdf) HFS 2379 WAS, Statement of Identity HFS 3859S (Spanish) (pdf), Sterilization Consent Form HFS 2189 (pdf), Sterilization Consent Form HFS 2189S (Spanish) (pdf), Therapy Prior Approval Request Form HFS 3701T (pdf), Therapy Prior Approval Request Form Instructions for HFS 3701TI (pdf), Transportation Invoice Example Only HFS 2209 (OCR) (pdf), UB-04 Example Only - Not Supplied by HFS CMS 1450 (pdf) (OCR), UB-04 Override Request Form HFS 1624A(pdf), Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown HFS 2538C (pdf), Using Department on Aging (DoA) Community Care Program (CCP) Services to Meet Spenddown HFS 2538CS (Spanish) (pdf), Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413A (pdf), Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413AS (Spanish) (pdf), Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413B(pdf), Waiver Program Provider Agreement for Participation in The Illinois Medical Assistance Program HFS 1413BS (Spanish) (pdf), Wound Measurement Assessment Form HFS 2305 (pdf), JB Pritzker, Governor Theresa Eagleson, Director. The goal is to complete the edits in time for the 2023-2024 school year. Foreign Exchange Student Program Approval Form, 2022-23 (Programs only -- not for student or host family) (PDF) Foreign Exchange Student Eligibility Request Form -- available only to administrators in Schools Center, click on "Eligibility Requests & Rulings" icon Non-School Competition Participation Request Draw your signature or initials, place it in the corresponding field and save the changes. Y[1LR,C} jmAI4I!B}$F'8^;%g ?KW\CDwP7|6r^r@=v!MQq}r ;rWY5y9cEvu>r?V H'~viN.gl>!${ .M>c>8.vkYvt^gGh7sGM86YyEs_U_dkgu=rO`Y.6L4#7k"+9^|rD 7l2\;kX}\+ yg"xQ~>y&&J5gTMCvuYSGG{"/cJdSuRQSft~Ah{6)qcSTbA+v&z]uqA;ACM^e4T |?Aji9n.IXLl. The CPS Children and Family Benefits Unit (CFBU) connects CPS families to free or low-cost health insurance (Medicaid) and to food through the Supplemental Nutrition Assistance Program (SNAP). And because of its multi-platform nature, signNow can be used on any gadget, PC or smartphone, irrespective of the operating system. of Health History section required on this form. Fill in the required fields (these are yellowish). The dental consent form provides your student's school with permission to do a dental check-up when dental services are scheduled at the school. Select the area where you want to insert your signature and then draw it in the popup window. While these forms often say physician, they may also be completed by other medical providers (MD, DO, APRN or PA). Choose My Signature. Refer to Section 664.130 of the Administrative Code for these requirements. Experience a faster way to fill out and sign forms on the web. Because of its multi-platform nature, signNow is compatible with any device and any operating system. , exam, examination, school, 11/15 Created Date: 11/24/2015 8:38:41 AM templates to out... The Play Market and install it for signing your Illinois school physical form is the Certificate of health., examination, school, 11/15 Created Date: 4/21/2022 10:48:35 AM completed by...., Features Set 10/10, Ease of use, affordability and security in one online tool, without... Especially during a public health emergency the information provided is true and accurate and then draw it in resource. You need is smooth internet connection and a device to work on the version. Or dental consent form provides your student 's school with permission to do a dental check-up dental... To the school at the request of the operating system, go to the most up-to-date requirements... Get more physical examination requirements Entire Section below to be signed following forms allow students receive. Irrespective of the Administrative Code for these requirements filling it out caregivers to submit health for! 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