%PDF-1.6
%
1 0 obj
<<
/AcroForm 2 0 R
/Lang (en-US)
/MarkInfo <<
/Marked true
>>
/Metadata 3 0 R
/Pages 4 0 R
/StructTreeRoot 5 0 R
/Type /Catalog
>>
endobj
6 0 obj
<<
/Author (Comm & Doc Mgmt)
/CreationDate (D:20170721104907-04'00')
/Creator <4D6963726F736F6674AE20576F72642032303130>
/ModDate (D:20210901102831-04'00')
/Producer <4D6963726F736F6674AE20576F72642032303130>
/Title (Mental Health Prior Authorization Form)
>>
endobj
2 0 obj
<<
/DA (/Helv 0 Tf 0 g )
/DR <<
/Encoding <<
/PDFDocEncoding 7 0 R
>>
/Font <<
/Helv 8 0 R
/ZaDb 9 0 R
>>
/XObject <<
/DSz 10 0 R
>>
>>
/Fields [11 0 R 12 0 R 13 0 R 14 0 R 15 0 R 16 0 R 17 0 R 18 0 R 19 0 R 20 0 R
21 0 R 22 0 R 23 0 R 24 0 R 25 0 R 26 0 R 27 0 R 28 0 R 29 0 R 30 0 R
31 0 R 32 0 R 33 0 R 34 0 R 35 0 R 36 0 R 37 0 R 38 0 R 39 0 R 40 0 R
41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R 49 0 R 50 0 R
51 0 R 52 0 R 53 0 R 54 0 R]
/SigFlags 1
>>
endobj
3 0 obj
<<
/Length 3473
/Subtype /XML
/Type /Metadata
>>
stream
application/pdf
Comm & Doc Mgmt
2017-07-21T10:49:07-04:00
Microsoft® Word 2010
2021-09-01T10:28:31-04:00
2021-09-01T10:28:31-04:00
Microsoft® Word 2010
uuid:696f1f6a-40fe-4dbb-a9b9-e9f15156bc15
uuid:56b2d3ae-173a-4b47-a306-053dd26d4cb2
1
1.1
endstream
endobj
4 0 obj
<<
/Count 1
/Kids [55 0 R]
/Type /Pages
>>
endobj
5 0 obj
<<
/K [56 0 R]
/ParentTree 57 0 R
/ParentTreeNextKey 1
/RoleMap 58 0 R
/Type /StructTreeRoot
>>
endobj
7 0 obj
<<
/Differences [24 /breve /caron /circumflex /dotaccent /hungarumlaut /ogonek /ring /tilde 39
/quotesingle 96 /grave 128 /bullet /dagger /daggerdbl /ellipsis /emdash /endash
/florin /fraction /guilsinglleft /guilsinglright /minus /perthousand /quotedblbase /quotedblleft /quotedblright /quoteleft
/quoteright /quotesinglbase /trademark /fi /fl /Lslash /OE /Scaron /Ydieresis /Zcaron
/dotlessi /lslash /oe /scaron /zcaron 160 /Euro 164 /currency 166
/brokenbar 168 /dieresis /copyright /ordfeminine 172 /logicalnot /.notdef /registered /macron
/degree /plusminus /twosuperior /threesuperior /acute /mu 183 /periodcentered /cedilla /onesuperior
/ordmasculine 188 /onequarter /onehalf /threequarters 192 /Agrave /Aacute /Acircumflex /Atilde
/Adieresis /Aring /AE /Ccedilla /Egrave /Eacute /Ecircumflex /Edieresis /Igrave /Iacute
/Icircumflex /Idieresis /Eth /Ntilde /Ograve /Oacute /Ocircumflex /Otilde /Odieresis /multiply
/Oslash /Ugrave /Uacute /Ucircumflex /Udieresis /Yacute /Thorn /germandbls /agrave /aacute
/acircumflex /atilde /adieresis /aring /ae /ccedilla /egrave /eacute /ecircumflex /edieresis
/igrave /iacute /icircumflex /idieresis /eth /ntilde /ograve /oacute /ocircumflex /otilde
/odieresis /divide /oslash /ugrave /uacute /ucircumflex /udieresis /yacute /thorn /ydieresis]
/Type /Encoding
>>
endobj
8 0 obj
<<
/BaseFont /Helvetica
/Encoding 7 0 R
/Name /Helv
/Subtype /Type1
/Type /Font
>>
endobj
9 0 obj
<<
/BaseFont /ZapfDingbats
/Name /ZaDb
/Subtype /Type1
/Type /Font
>>
endobj
10 0 obj
<<
/BBox [0.0 0.0 100.0 100.0]
/Length 10
/Resources <<
>>
/Subtype /Form
/Type /XObject
>>
stream
% DSBlank
endstream
endobj
11 0 obj
<<
/AP <<
/N 59 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [21.8899 660.095 292.74 678.095]
/Subtype /Widget
/T (Patient Last Name)
/Type /Annot
>>
endobj
12 0 obj
<<
/AP <<
/N 60 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [306.002 659.639 590.078 677.639]
/Subtype /Widget
/T (Patient First Name)
/Type /Annot
>>
endobj
13 0 obj
<<
/AP <<
/N 61 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [21.4338 628.628 293.196 646.628]
/Subtype /Widget
/T (Patient Member ID Number)
/Type /Annot
>>
endobj
14 0 obj
<<
/AA <<
/F 62 0 R
/K 63 0 R
>>
/AP <<
/N 64 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [306.914 628.172 542.65 646.524]
/Subtype /Widget
/T (Patient Date of Birth)
/Type /Annot
>>
endobj
15 0 obj
<<
/DA (/ZaDb 0 Tf 0 g)
/FT /Btn
/Ff 49152
/Kids [65 0 R 66 0 R]
/T (Gender)
/TU (Gender)
>>
endobj
16 0 obj
<<
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
>>
/P 55 0 R
/Rect [91.2078 602.178 590.99 616.425]
/Subtype /Widget
/T (Medical Diagnosis)
/Type /Annot
>>
endobj
17 0 obj
<<
/AP <<
/N 67 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [250.84 573.426 361.164 587.826]
/Subtype /Widget
/T (Strength)
/Type /Annot
>>
endobj
18 0 obj
<<
/AP <<
/N 68 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [379.482 564.267 591.047 578.666]
/Subtype /Widget
/T (Brand Medically Necessary)
/Type /Annot
>>
endobj
19 0 obj
<<
/AP <<
/N 69 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [90.8475 546.442 382.22 560.842]
/Subtype /Widget
/T (Dosing Directions)
/Type /Annot
>>
endobj
20 0 obj
<<
/AP <<
/N 70 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [66.5817 573.447 216.582 587.847]
/Subtype /Widget
/T (Drug Name)
/Type /Annot
>>
endobj
21 0 obj
<<
/DA (/ZaDb 0 Tf 0 g)
/FT /Btn
/Ff 49152
/Kids [71 0 R 72 0 R]
/T (Therapy)
/TU (Therapy)
>>
endobj
22 0 obj
<<
/AP <<
/N 73 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [470.311 547.316 592.492 561.716]
/Subtype /Widget
/T (Length of Therapy)
/Type /Annot
>>
endobj
23 0 obj
<<
/AP <<
/N 74 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [306.933 479.786 590.096 498.138]
/Subtype /Widget
/T (Prescriber First Name)
/Type /Annot
>>
endobj
24 0 obj
<<
/AP <<
/N 75 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [21.0348 447.825 283.22 466.177]
/Subtype /Widget
/T (Prescriber Specialty)
/Type /Annot
>>
endobj
25 0 obj
<<
/AP <<
/N 76 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [306.098 446.418 568.283 464.77]
/Subtype /Widget
/T (Prescriber NPI Number)
/Type /Annot
>>
endobj
26 0 obj
<<
/AP <<
/N 77 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [306.631 414.874 592.531 433.226]
/Subtype /Widget
/T (Prescriber Fax Number)
/Type /Annot
>>
endobj
27 0 obj
<<
/AP <<
/D <<
/Brand 78 0 R
/Off 79 0 R
>>
/N <<
/Brand 80 0 R
/Off 81 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [363.463 578.534 371.413 587.238]
/Subtype /Widget
/T (Brand)
/TU (Brand)
/Type /Annot
>>
endobj
28 0 obj
<<
/AP <<
/D <<
/Drug-to-drug#20Interaction 82 0 R
/Off 83 0 R
>>
/N <<
/Drug-to-drug#20Interaction 84 0 R
/Off 85 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [110.361 356.899 118.767 365.604]
/Subtype /Widget
/T (Drug-to-drug Interaction)
/TU (Drug-to-drug Interaction)
/Type /Annot
>>
endobj
29 0 obj
<<
/AP <<
/N 86 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [438.5 529.19 593.06 543.59]
/Subtype /Widget
/T (Therapy Start Date)
/Type /Annot
>>
endobj
30 0 obj
<<
/AP <<
/D <<
/Allergic#20Reaction 87 0 R
/Off 88 0 R
>>
/N <<
/Allergic#20Reaction 89 0 R
/Off 90 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.1536 356.443 27.1034 365.147]
/Subtype /Widget
/T (Allergic Reaction)
/TU (Allergic Reaction)
/Type /Annot
>>
endobj
31 0 obj
<<
/AP <<
/N 91 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [459.706 349.511 600.129 374.856]
/Subtype /Widget
/T (Describe Reaction)
/Type /Annot
>>
endobj
32 0 obj
<<
/AP <<
/D <<
/Off 92 0 R
/Previous#20Episode 93 0 R
>>
/N <<
/Off 94 0 R
/Previous#20Episode 95 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.0551 340.046 27.0049 348.75]
/Subtype /Widget
/T (Previous Episode)
/TU (Previous Episode)
/Type /Annot
>>
endobj
33 0 obj
<<
/AP <<
/N 96 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [28.9769 321.692 599.901 339.285]
/Subtype /Widget
/T (Unacceptable side effect or therapeutic failure)
/Type /Annot
/V ( \r)
>>
endobj
34 0 obj
<<
/AP <<
/D <<
/Contraindication 97 0 R
/Off 98 0 R
>>
/N <<
/Contraindication 99 0 R
/Off 100 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.0551 314.507 27.0049 323.212]
/Subtype /Widget
/T (Contraindication)
/TU (Contraindication)
/Type /Annot
>>
endobj
35 0 obj
<<
/AP <<
/N 101 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [29.4329 296.838 600.357 313.974]
/Subtype /Widget
/T (Contraindication to a preferred drug)
/Type /Annot
>>
endobj
36 0 obj
<<
/AP <<
/D <<
/Age#20Specific#20Indications 102 0 R
/Off 103 0 R
>>
/N <<
/Age#20Specific#20Indications 104 0 R
/Off 105 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.0551 289.425 27.0049 298.129]
/Subtype /Widget
/T (Age Specific Indications)
/TU (Age Specific Indications)
/Type /Annot
>>
endobj
37 0 obj
<<
/AP <<
/N 106 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [29.4329 271.528 600.357 288.664]
/Subtype /Widget
/T (Age specific indications)
/Type /Annot
/V (\r )
>>
endobj
38 0 obj
<<
/AP <<
/D <<
/Age#20Specific#20Indications 107 0 R
/Off 108 0 R
>>
/N <<
/Age#20Specific#20Indications 109 0 R
/Off 110 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.0551 263.887 27.0049 272.591]
/Subtype /Widget
/T (Clinical indication)
/TU (Clinical indication)
/Type /Annot
>>
endobj
39 0 obj
<<
/AP <<
/D <<
/Off 111 0 R
/Unacceptable#20risk 112 0 R
>>
/N <<
/Off 113 0 R
/Unacceptable#20risk 114 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [19.2523 239.717 26.8078 248.421]
/Subtype /Widget
/T (Unacceptable risk)
/TU (Unacceptable risk)
/Type /Annot
>>
endobj
40 0 obj
<<
/AP <<
/D <<
/Conditional#20Discharge 115 0 R
/Off 116 0 R
>>
/N <<
/Conditional#20Discharge 117 0 R
/Off 118 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [37.0378 221.475 44.5933 230.18]
/Subtype /Widget
/T (Conditional Discharge)
/TU (Unacceptable risk)
/Type /Annot
>>
endobj
41 0 obj
<<
/AP <<
/D <<
/30#20day#20discharge 119 0 R
/Off 120 0 R
>>
/N <<
/30#20day#20discharge 121 0 R
/Off 122 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [36.6203 211.404 44.1759 219.196]
/Subtype /Widget
/T (30 day discharge)
/TU (30 day discharge)
/Type /Annot
>>
endobj
42 0 obj
<<
/AP <<
/D <<
/ACT#20services 123 0 R
/Off 124 0 R
>>
/N <<
/ACT#20services 125 0 R
/Off 126 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [36.5817 202.322 44.5933 209.658]
/Subtype /Widget
/T (ACT services)
/TU (ACT services)
/Type /Annot
>>
endobj
43 0 obj
<<
/AP <<
/N 127 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [29.8889 247.358 600.813 263.582]
/Subtype /Widget
/T (Unique clinical indication)
/Type /Annot
/V ( )
>>
endobj
44 0 obj
<<
/AP <<
/D <<
/Off 128 0 R
/Other 129 0 R
>>
/N <<
/Off 130 0 R
/Other 131 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [37.1537 192.173 44.7092 200.877]
/Subtype /Widget
/T (Other)
/TU (Unacceptable risk)
/Type /Annot
>>
endobj
45 0 obj
<<
/AP <<
/N 132 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [119.975 181.688 601.972 201.561]
/Subtype /Widget
/T (Please explain)
/Type /Annot
/V ( )
>>
endobj
46 0 obj
<<
/AP <<
/N 10 0 R
>>
/DA (/Helv 0 Tf 0 g)
/F 4
/FT /Sig
/MK <<
>>
/P 55 0 R
/Rect [134.532 114.705 393.525 135.76]
/Subtype /Widget
/T (Prescriber's Signature)
/Type /Annot
>>
endobj
47 0 obj
<<
/AA <<
/F 133 0 R
/K 134 0 R
>>
/DA (/Helv 11 Tf 0 g)
/FT /Tx
/Kids [135 0 R 136 0 R]
/T (Date)
>>
endobj
48 0 obj
<<
/AP <<
/N 137 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [21.4338 479.959 283.619 498.311]
/Subtype /Widget
/T (Prescriber Last Name)
/Type /Annot
>>
endobj
49 0 obj
<<
/DA (/Helv 11 Tf 0 g)
/FT /Tx
/Kids [138 0 R 139 0 R]
/T (Prescriber Phone Number)
>>
endobj
50 0 obj
<<
/AP <<
/N 140 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [135.006 95.3454 359.34 110.961]
/Subtype /Widget
/T (Prescriber Printed Name)
/Type /Annot
>>
endobj
51 0 obj
<<
/AP <<
/N 141 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [208.2 78.0159 360.024 93.6313]
/Subtype /Widget
/T (Contact Person for Peer to Peer)
/Type /Annot
>>
endobj
52 0 obj
<<
/AP <<
/N 142 0 R
>>
/DA (/Helv 11 Tf 0 g)
/F 4
/FT /Tx
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [424.591 77.1038 589.64 92.7193]
/Subtype /Widget
/T (Contact Person Phone Number)
/Type /Annot
>>
endobj
53 0 obj
<<
/AP <<
/D <<
/Medical#20information 143 0 R
/Off 144 0 R
>>
/N <<
/Medical#20information 145 0 R
/Off 146 0 R
>>
>>
/AS /Off
/F 4
/FT /Btn
/Ff 49152
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Rect [18.6976 169.923 27.1034 178.628]
/Subtype /Widget
/T (Medical information)
/TU (Medical information)
/Type /Annot
>>
endobj
54 0 obj
<<
/AP <<
/N 147 0 R
>>
/F 4
/FT /Tx
/Ff 4096
/MK <<
/BG [1.0 1.0 1.0]
>>
/P 55 0 R
/Rect [28.2744 156.171 601.935 169.507]
/Subtype /Widget
/T (Provide medical information)
/TU (Provide medical information)
/Type /Annot
/V (\r)
>>
endobj
55 0 obj
<<
/Annots [135 0 R 11 0 R 12 0 R 13 0 R 14 0 R 65 0 R 66 0 R 16 0 R 20 0 R 17 0 R
18 0 R 19 0 R 22 0 R 71 0 R 72 0 R 29 0 R 27 0 R 48 0 R 23 0 R 24 0 R
25 0 R 138 0 R 26 0 R 30 0 R 28 0 R 31 0 R 32 0 R 33 0 R 34 0 R 35 0 R
36 0 R 37 0 R 38 0 R 43 0 R 39 0 R 40 0 R 41 0 R 44 0 R 42 0 R 45 0 R
46 0 R 136 0 R 50 0 R 139 0 R 51 0 R 52 0 R 53 0 R 54 0 R]
/Contents [148 0 R 149 0 R 150 0 R 151 0 R 152 0 R 153 0 R 154 0 R 155 0 R]
/CropBox [0 0 612 792]
/Group <<
/CS /DeviceRGB
/S /Transparency
/Type /Group
>>
/MediaBox [0 0 612 792]
/Parent 4 0 R
/Resources <<
/Font <<
/C2_0 156 0 R
/C2_1 157 0 R
/C2_2 158 0 R
/C2_3 159 0 R
/C2_4 160 0 R
/C2_5 161 0 R
/C2_6 162 0 R
/TT0 163 0 R
/TT1 164 0 R
/TT2 165 0 R
/TT3 166 0 R
/TT4 167 0 R
/TT5 168 0 R
>>
/ProcSet [/PDF /Text /ImageB]
/XObject <<
/Im0 169 0 R
>>
>>
/Rotate 0
/StructParents 0
/Tabs /S
/Type /Page
>>
endobj
56 0 obj
<<
/K [170 0 R 171 0 R 172 0 R 173 0 R 174 0 R 175 0 R 176 0 R 177 0 R 178 0 R 179 0 R
180 0 R 181 0 R 182 0 R 183 0 R 184 0 R 185 0 R 186 0 R 187 0 R 188 0 R 189 0 R
190 0 R 191 0 R 192 0 R]
/P 5 0 R
/S /Part
/Type /StructElem
>>
endobj
57 0 obj
<<
/Nums [0 [170 0 R 193 0 R 194 0 R 194 0 R 194 0 R 194 0 R 194 0 R 194 0 R 194 0 R 194 0 R
195 0 R 196 0 R 197 0 R 198 0 R 198 0 R 199 0 R 200 0 R 201 0 R 202 0 R 203 0 R
204 0 R 205 0 R 206 0 R 207 0 R 208 0 R 209 0 R 210 0 R 211 0 R 212 0 R 213 0 R
214 0 R 214 0 R 215 0 R 216 0 R 217 0 R 218 0 R 219 0 R 220 0 R 221 0 R 222 0 R
223 0 R 224 0 R 225 0 R 226 0 R 227 0 R 228 0 R 229 0 R 230 0 R 230 0 R 231 0 R
232 0 R 233 0 R 234 0 R 235 0 R 235 0 R 236 0 R 237 0 R 238 0 R 239 0 R 240 0 R
241 0 R 242 0 R 243 0 R 244 0 R 245 0 R 246 0 R 247 0 R 248 0 R 172 0 R 173 0 R
249 0 R 250 0 R 175 0 R 176 0 R 177 0 R 251 0 R 252 0 R 253 0 R 254 0 R 179 0 R
255 0 R 256 0 R 257 0 R 258 0 R 181 0 R 259 0 R 260 0 R 260 0 R 260 0 R 260 0 R
260 0 R 260 0 R 260 0 R 261 0 R 262 0 R 263 0 R 264 0 R 264 0 R 265 0 R 266 0 R
267 0 R 268 0 R 269 0 R 270 0 R 271 0 R 272 0 R 273 0 R 274 0 R 275 0 R 276 0 R
277 0 R 278 0 R 279 0 R 280 0 R 280 0 R 281 0 R 282 0 R 283 0 R 284 0 R 285 0 R
286 0 R 287 0 R 288 0 R 289 0 R 290 0 R 291 0 R 292 0 R 293 0 R 294 0 R 295 0 R
296 0 R 297 0 R 298 0 R 299 0 R 300 0 R 301 0 R 301 0 R 302 0 R 303 0 R 304 0 R
305 0 R 306 0 R 307 0 R 308 0 R 309 0 R 310 0 R 311 0 R 312 0 R 313 0 R 314 0 R
315 0 R 316 0 R 317 0 R 318 0 R 319 0 R 320 0 R 321 0 R 322 0 R 323 0 R 324 0 R
325 0 R 326 0 R 327 0 R 328 0 R 329 0 R 330 0 R 331 0 R 332 0 R 333 0 R 334 0 R
335 0 R 336 0 R 337 0 R 338 0 R 339 0 R 340 0 R 341 0 R 342 0 R 343 0 R 344 0 R
183 0 R 345 0 R 346 0 R 346 0 R 346 0 R 346 0 R 346 0 R 346 0 R 347 0 R 347 0 R
347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R
347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 347 0 R 348 0 R 185 0 R
186 0 R 349 0 R 349 0 R 349 0 R 349 0 R 350 0 R 350 0 R 350 0 R 350 0 R 350 0 R
350 0 R 350 0 R 350 0 R 351 0 R 352 0 R 353 0 R 353 0 R 353 0 R 353 0 R 354 0 R
355 0 R 356 0 R 357 0 R 358 0 R 358 0 R 358 0 R 358 0 R 358 0 R 358 0 R 358 0 R
358 0 R 359 0 R 360 0 R 361 0 R 361 0 R 361 0 R 361 0 R 361 0 R 362 0 R 363 0 R
364 0 R 364 0 R 364 0 R 364 0 R 364 0 R 364 0 R 364 0 R 364 0 R 365 0 R 366 0 R
367 0 R 368 0 R 368 0 R 368 0 R 368 0 R 368 0 R 368 0 R 368 0 R 368 0 R 368 0 R
369 0 R 370 0 R 371 0 R 372 0 R 373 0 R 374 0 R 375 0 R 376 0 R 376 0 R 376 0 R
376 0 R 376 0 R 376 0 R 376 0 R 376 0 R 376 0 R 376 0 R 376 0 R 376 0 R 377 0 R
378 0 R 379 0 R 380 0 R 188 0 R 189 0 R 190 0 R 191 0 R 192 0 R]
]
>>
endobj
58 0 obj
<<
/Annotation /Sect
/Artifact /Sect
/Chart /Sect
/Chartsheet /Part
/Diagram /Figure
/Dialogsheet /Part
/Endnote /Note
/Footer /Sect
/Footnote /Note
/Header /Sect
/InlineShape /Sect
/Macrosheet /Part
/Slide /Part
/Textbox /Sect
/Workbook /Document
/Worksheet /Part
>>
endobj
59 0 obj
<<
/BBox [0.0 0.0 270.85 16.5275]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 270.8503 16.5275 re
f
endstream
endobj
60 0 obj
<<
/BBox [0.0 0.0 284.075 17.4396]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 284.0755 17.4396 re
f
endstream
endobj
61 0 obj
<<
/BBox [0.0 0.0 271.762 17.4396]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 271.7624 17.4396 re
f
endstream
endobj
62 0 obj
<<
/JS (AFDate_FormatEx\("mm/dd/yyyy"\);)
/S /JavaScript
>>
endobj
63 0 obj
<<
/JS (AFDate_KeystrokeEx\("mm/dd/yyyy"\);)
/S /JavaScript
>>
endobj
64 0 obj
<<
/BBox [0.0 0.0 235.735 18.3517]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 235.7353 18.3517 re
f
endstream
endobj
65 0 obj
<<
/AP <<
/D <<
/Male 381 0 R
/Off 382 0 R
>>
/N <<
/Male 383 0 R
/Off 384 0 R
>>
>>
/AS /Off
/F 4
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Parent 15 0 R
/Rect [66.1257 617.298 74.0755 626.002]
/Subtype /Widget
/Type /Annot
>>
endobj
66 0 obj
<<
/AP <<
/D <<
/Female 385 0 R
/Off 386 0 R
>>
/N <<
/Female 387 0 R
/Off 388 0 R
>>
>>
/AS /Off
/DA (/ZaDb 0 Tf 0 g)
/F 4
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Parent 15 0 R
/Rect [101.241 616.842 109.19 625.546]
/Subtype /Widget
/Type /Annot
>>
endobj
67 0 obj
<<
/BBox [0.0 0.0 110.325 14.3999]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 110.3246 14.3999 re
f
endstream
endobj
68 0 obj
<<
/BBox [0.0 0.0 211.565 14.3999]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 211.5653 14.3999 re
f
endstream
endobj
69 0 obj
<<
/BBox [0.0 0.0 291.372 14.3999]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 291.3721 14.3999 re
f
endstream
endobj
70 0 obj
<<
/BBox [0.0 0.0 150.0 14.4]
/FormType 1
/Length 22
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 150 14.4 re
f
endstream
endobj
71 0 obj
<<
/AP <<
/D <<
/Initial 389 0 R
/Off 390 0 R
>>
/N <<
/Initial 391 0 R
/Off 392 0 R
>>
>>
/AS /Off
/F 4
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Parent 21 0 R
/Rect [75.7025 532.018 86.7841 540.722]
/Subtype /Widget
/Type /Annot
>>
endobj
72 0 obj
<<
/AP <<
/D <<
/Continuing 393 0 R
/Off 394 0 R
>>
/N <<
/Continuing 395 0 R
/Off 396 0 R
>>
>>
/AS /Off
/F 4
/MK <<
/BC [0.0 0.0 0.0]
/BG [1.0 1.0 1.0]
/CA (n)
>>
/P 55 0 R
/Parent 21 0 R
/Rect [111.889 532.494 121.147 541.198]
/Subtype /Widget
/Type /Annot
>>
endobj
73 0 obj
<<
/BBox [0.0 0.0 122.182 14.3999]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 122.1816 14.3999 re
f
endstream
endobj
74 0 obj
<<
/BBox [0.0 0.0 283.163 18.3517]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 283.1632 18.3517 re
f
endstream
endobj
75 0 obj
<<
/BBox [0.0 0.0 262.186 18.3517]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 262.1856 18.3517 re
f
endstream
endobj
76 0 obj
<<
/BBox [0.0 0.0 262.186 18.3517]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 262.1856 18.3517 re
f
endstream
endobj
77 0 obj
<<
/BBox [0.0 0.0 285.9 18.3517]
/FormType 1
/Length 30
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
1 g
0 0 285.8996 18.3517 re
f
endstream
endobj
78 0 obj
<<
/BBox [0.0 0.0 7.9498 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 130
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/Font <<
/ZaDb 9 0 R
>>
/ProcSet [/PDF /Text]
>>
/Subtype /Form
/Type /XObject
>>
stream
H<
ADl.mEw`q?zp0'VE;!$\*bJ6 /yƾ^HA^S{6FE)('kMU:;58ڰO'| F8
endstream
endobj
79 0 obj
<<
/BBox [0.0 0.0 7.9498 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 60
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
H237402VH2P0P0׳4P3701R(JJ
s*D.]`
endstream
endobj
80 0 obj
<<
/BBox [0.0 0.0 7.9498 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 126
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/Font <<
/ZaDb 9 0 R
>>
/ProcSet [/PDF /Text]
>>
/Subtype /Form
/Type /XObject
>>
stream
H<
@D)Yݥp )@@<&pR63KR7~^k}J9qi_,"⊩.
v{K6M,=LW2I{'\[B-6Ӗeı iB
endstream
endobj
81 0 obj
<<
/BBox [0.0 0.0 7.9498 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 53
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
H2TH2P0P0׳4P3701R(JJ
s*D.]` K@
endstream
endobj
82 0 obj
<<
/BBox [0.0 0.0 8.40584 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 127
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/Font <<
/ZaDb 9 0 R
>>
/ProcSet [/PDF /Text]
>>
/Subtype /Form
/Type /XObject
>>
stream
H<α
A~bJmb.Y[Qll`X\1[Je}mᚍ'V>/;Lm9b\o;TSg0I:M41Rr NXMk? X^|
endstream
endobj
83 0 obj
<<
/BBox [0.0 0.0 8.40584 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 59
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/ProcSet [/PDF]
>>
/Subtype /Form
/Type /XObject
>>
stream
H237402VH2P0P310 R&F
E\i@aw.=S6Hå
endstream
endobj
84 0 obj
<<
/BBox [0.0 0.0 8.40584 8.70416]
/Filter /FlateDecode
/FormType 1
/Length 121
/Matrix [1.0 0.0 0.0 1.0 0.0 0.0]
/Resources <<
/Font <<
/ZaDb 9 0 R
>>
/ProcSet [/PDF /Text]
>>
/Subtype /Form
/Type /XObject
>>
stream
H<˱
@~bJmֽ XO)汉*Y5?Om>B|a_7e9a쮷Y3Ft:Mܴc