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CONFIDENTIAL MEDICAL INFORMATION The information submitted on this form is confidential and will not be available for public inspection. Upon request, the State of Ohio will be permitted to view this form. Name of Defendant___________________________________Case No._________________ 1. Name and address of Medical Provider________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Location of services, if different than above_____________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 2. Name and address of Medical Provider________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Location of services, if different than above_____________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ 3. Name and address of Medical Provider________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ Location of services, if different than above_____________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________ ________________________________________________________________