Form Fc 2 Cl - Audit Contact Log

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
AUDIT CONTACT LOG
INSTRUCTIONS: This form is intended to document contacts and may include telephone calls (t/c) and office visits (o/v).
Enter relevant information including action taken and follow up .
PROVIDER NAME:
PROGRAM NO.:
DATE
INCLUDE NAME OF CONTACT AND EXPLANATION
INITIALS
FC 2 CL (11/02)
PAGE ________ OF ________

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