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Because you have indicated that you do not see patients at the above listed address, the American with Disabilities Act Attestion Form questions are not applicable to you.
Please electronically sign this form and submit it.
Electronic Signature
I hereby attest that we are a provider that has a physical site at which Participants might possibly be physically present and that the answers provided are accurate. Also, I do hereby attest that I hold the authority to make these attestations.