VIRGINIA LOAN REPAYMENT PROGRAM

A. Number of persons served by this practice site: B. Number of users with income below 200% of federal poverty level: C. Number of users on Medicaid: Medicaid Provider Number: D. Number of users on Medicare: E. Service area/county 5-year average infant mortality rate (if known): F. Service area/county 5-year average rate of low birth weight ... ................
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