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* 1. Organization Name

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* 2. Site Name

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* 3. Address

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* 4. Phone

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* 5. Site (Non-Referral) Services Provided
(See Site and Service Audit Definition sheet for clarification of terms with an asterisk.)

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* 6. Other Specialty Care (please explain)

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* 7. Hours Open per Week (check one)

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* 8. Weekends and Evenings (check all that apply)

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* 9. Section 330 Grant Types for this Site (check all that apply)

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* 10. Name

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* 11. Title

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* 12. Email

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* 13. Phone

Questions can be directed to Barry Lacy at blacy@iphca.org or (217) 353-1326.

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