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Ann Marie T. Sullivan, M.D., Acting Commissioner
Governor Andrew M. Cuomo

Result of Screening

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Date:

Dear :

The referral packet of your child , has been screened and reviewed.  It appears that he/she

Sincerely,

Signature
Agency
Print Name
Address
Title
Telephone

cc:

Individualized Care Coordinator
Referral Source
LGU File

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