Attending Provider Treatment Plan

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36. DIAGNOSIS OR NATURE OF ILLNESS OR INJURY (Relate A-L to service line below using Diagnosis Pointer in section 38 below)
Purchase
Rental
I HAVE PERSONALLY COMPLETED AND PREVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
AC-PIP17w (3/16)
APTP FORM VERSION 2.1 (3/2016)

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