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DHCF Telehealth Emergency Response Questionnaire
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* Indicates required question
Provider/ Practice Name
*
Your answer
State of Residence
*
Your answer
Practice (Organization) NPI
*
Your answer
Practice Location- Street Address
*
Your answer
Practice Location- City, State, and Zip Code
*
Your answer
Practice Location- Ward
Your answer
Specify the number of Medicaid patients served annually
*
Your answer
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