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Tuesday, September 07, 2010
   
DQA Public Information Request

The DQA Bureau of Information and Operational Support processes public information requests pertaining to entities (e.g. health care providers, suppliers, etc.) regulated by the Division of Quality Assurance.
     
    Requester Contact Information
     
  1. First Name*

  2. Last Name*

  3. Entity

  4. Address*

  5. City/State/Zip*

  6. Telephone

  7. E-mail Address*

    8.  
    Request Detail
     
  8. Facility/Entity Name

  9. Address

  10. City/State/Zip

  11. Request Category*

  12. Request Description*

 

Ohio Department of Health © 2006
All information is strictly CONFIDENTIAL