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Please complete sections A, B and C - centegra 2026
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- Click ‘Get Form’ to open it in the editor.
- In Section A, enter the date, employer/company name, and employee or applicant name. Ensure that the patient has a photo I.D. for verification.
- Provide the name of the employer representative authorizing the service and their primary phone number along with a cell or other contact number.
- Move to Section B and indicate the purpose of the visit by checking the appropriate boxes. If applicable, specify any different protocols for various positions.
- In Section C, provide instructions for the services required. You can either follow standard company protocols or specify particular services needed.
- Finally, ensure that an authorized representative signs at the bottom of Section C to validate the form.
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Related links
Jun 26, 2025 Administrative Rules to complete this section. linking Buildings B and C, an additional opportunity arose to address many campuswide issues.
If you checked 12a of Part I, complete Sections A and B. If you checked 12b of Part I, complete Sections A and C If you checked 12c of Part I,