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Physician Data Discrepancy Form

Submitter Information

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Multipage

Submitter Information
Submitter Information
YYYY-MM-DD
Field is invalidField is validThis field is required.
Field is invalidField is validPlease enter a valid date in YYYY-MM-DD format.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
XXX-XXX-XXXX
Field is invalidField is validPlease enter a valid telephone number.
XXX-XXX-XXXX
Field is invalidField is validPlease enter a valid telephone number.
Field is invalidField is validPlease enter a valid e-mail address.
Physician Information

Please provide the following information to help the AMA identify the physician with a data discrepancy.

Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
Field is invalidField is validThis field is required.
YYYY-MM-DD
Field is invalidField is validThis field is required.
Field is invalidField is validPlease enter a valid date in YYYY-MM-DD format.
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