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Description of child care provider medical report
STATE OF TENNESSEE DEPARTMENT OF HUMAN SERVICES CHILD CARE PROVIDER MEDICAL REPORT A. TO BE COMPLETED BY PROVIDER Name Birth Date Address Street City State Zip Code I hereby authorize the physician s name below to release information Provider/Patient s Signature to the Department of Human Services for approval/licensure or employment as a child care provider. Address Name of Physician s Purpose of Examination...
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child care provider medical report
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