Activity Prescription Form (APF) (F242-385-000)
DATE (month and year) for EACH admission . MUST . be provided: Other (Specify): 2. PURPOSE: (Providing information about the purpose of the request is . strictly voluntary; however, it may help to provide the best possible response and may result in a faster reply. Information provided will in no way be used to make a decision to deny the request.) ................
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