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Application for Medical Staff Appointment Indian Health Service Ihs Form
Court records, etc) of your response if requested. You may choose to have
your attorney complete this form.
Date of Incident:
1. Date of Claim:
2. Where incident occurred:
3. Claimant/patient name:
4. Nature of incident (type of case, procedure, major allegation, other pertinent
information:
5. Current status:
Pending/Open or
Closed
(date)
If closed, indicate:
Dropped
Dismissed
Appeal:
Judgment for plaintiff: $
TN 2008-19
(11/19/2008)
Judgment for defendant (you)
Settled: $
Manual...
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