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1. Select your facility provider number and name.

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2. Date when facility operations were interrupted.

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3. What caused this interruption of operations?

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4. Facility operational status.

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5. Have all of your patients been notified of the changes to their treatment schedule?
* If not please call Network 4 Patient Services at: 610-265-2418 ext 2831 or 2830.

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6. When do you expect normal operations to resume?

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