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Table of Contents

Document Id
Document Created:
Confidentiality Normal Restricted Very restricted
Author ,
Contact info
Signed at
Contact info
Legal authenticator at
Contact info
Entered by
Contact info
Encounter Id
Encounter Type
Encounter Id
Encounter Date  at   From  to
Encounter Location of id:
Responsible party
Contact info
Document maintained by
Contact info
 at   from  to
In fulfillment of    
Informant
Contact info
Contact info
Information recipient:


Contact info
Participant from to
Contact info
Patient
Date of birth
Sex
Race Information not available
Ethnicity Information not available
Contact info
Patient IDs
Related document
Consent
SetId and Version SetId: Version:
,