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AHCA Form 1823, Mar 2017 [58A-5.0181(2)(b), F.A.C.] Page 2 of 2. NOTE: “Resident Name” and “DOB” below will not update until the form is printed or previewed. To Be Completed By Facility: Resident Name: DOB: Authorized Representative (if applicable): AHCA Form 1823, Mar 2017 [58A-5.0181(2)(b), F.A.C.] Page 1 of 8 ... ................
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