Please fax or mail the completed form to your designated ministry staff contact person.
Name of Contact Person Fax No. Date Faxed (yyyy/mm/dd)
Name of Group Group Registration Number Fax No.
Location Address Telephone No. Monday Tuesday Wednesday Thursday Friday Saturday Sunday
In accordance with this agreement, we are notifying our patients about our after hours services in the following manner; (e.g. posting of after hours schedule in waiting room).
Print Name of Designated Contact Physician Signature of Designated Contact Physician Date (yyyy/mm/dd)
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