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Application for Medical Staff Appointment Indian Health Service Ihs  Form

Application for Medical Staff Appointment Indian Health Service Ihs Form

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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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