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Click ‘Get Form’ to open it in the editor.
Begin with Part 1 if you are a licensed physician. Fill in your name, address, city, state, and zip code.
Certify the patient's condition by entering their name and indicating whether their disability is permanent or temporary by circling the appropriate option.
Check the relevant boxes (A through E) that describe the patient's condition based on the criteria provided.
Sign and date the form at the bottom of Part 1.
If you are an organization, complete Part 2 by filling in your organization's name, address, city, state, zip code, and Federal Employer Identification Number.
Certify that your organization owns a vehicle for transporting persons with disabilities by signing and dating at the bottom of Part 2.
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Rules 336 - Appeal of Child Abuse and Neglect Investigation
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