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Child Health Record Form
USUALLY CARED FOR DURING THE DAY BY
PHONE
Dentist
, RELATIONSHIP_
13. IN CASE OF EMERGENCY NOTIFY
8. LANGUAGE USUALLY SPOKEN AT HOME (If more than one,
place "1" by primary language):
English
I.Z
5
(1)
Relationship
Spanish
Phone
Other
9. SOURCE OF REIMBURSEMENT OR SERVICES (Circle "Yes"
or "No" for each source. Use pencil, keep current)
YES
NO
or
(2)
Relationship
Phone
EPSDT/Medicaid (Latest certification No.):
or
(3)
YES
NO
Relationship
Federal, State or Local...
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