%PDF-1.4 % 8 0 obj << /Linearized 1 /O 11 /H [ 1310 242 ] /L 36839 /E 34488 /N 1 /T 36562 >> endobj xref 8 33 0000000016 00000 n 0000001004 00000 n 0000001111 00000 n 0000001552 00000 n 0000001721 00000 n 0000001771 00000 n 0000001990 00000 n 0000002232 00000 n 0000002379 00000 n 0000002582 00000 n 0000002728 00000 n 0000003055 00000 n 0000003350 00000 n 0000003694 00000 n 0000003803 00000 n 0000005152 00000 n 0000005292 00000 n 0000005642 00000 n 0000005856 00000 n 0000006080 00000 n 0000006288 00000 n 0000006641 00000 n 0000007126 00000 n 0000009774 00000 n 0000010119 00000 n 0000010343 00000 n 0000010397 00000 n 0000014862 00000 n 0000026017 00000 n 0000029963 00000 n 0000034319 00000 n 0000001310 00000 n 0000001531 00000 n trailer << /Size 41 /Info 6 0 R /Root 9 0 R /Prev 36553 /ID[<67bf0fdf4d019598a778b2d939c0a619>] >> startxref 0 %%EOF 9 0 obj << /Type /Catalog /Pages 5 0 R /Metadata 7 0 R /PageLabels 4 0 R /AcroForm 10 0 R >> endobj 10 0 obj << /Fields [ 14 0 R 16 0 R 18 0 R 13 0 R ] /DR << /Font << /ZaDb 1 0 R /Helv 2 0 R /TiRo 21 0 R >> /Encoding << /PDFDocEncoding 22 0 R >> >> /DA (/Helv 0 Tf 0 g ) /SigFlags 0 >> endobj 39 0 obj << /S 36 /V 113 /L 142 /Filter /FlateDecode /Length 40 0 R >> stream Hb``g``c_lJ 3011a`r89AQPQa  *>RcQ~mA @ 17nRӀf6@ endstream endobj 40 0 obj 123 endobj 11 0 obj << /Type /Page /Parent 5 0 R /Resources 23 0 R /Contents 30 0 R /MediaBox [ 0 0 612 792 ] /CropBox [ 0 0 612 792 ] /Rotate 0 /Annots 12 0 R >> endobj 12 0 obj [ 13 0 R 14 0 R 16 0 R 18 0 R ] endobj 13 0 obj << /Type /Annot /Subtype /Widget /Rect [ 72.13245 118.21738 253.28325 149.36548 ] /DA (/TiRo 10 Tf 0 g) /P 11 0 R /FT /Tx /T (Signature) /TU (Signature of patient or sponsor.) /MK << >> /F 4 >> endobj 14 0 obj << /Type /Annot /Subtype /Widget /Rect [ 259.02106 119.85675 428.69624 149.36548 ] /F 4 /P 11 0 R /FT /Tx /T (SSN) /TU (Social Security Number of member or sponsor.) /DA (/TiRo 10 Tf 0 g) /AP << /N 15 0 R >> /Q 1 >> endobj 15 0 obj << /Length 11 /Subtype /Form /BBox [ 0 0 169.67519 29.50873 ] /Resources << /ProcSet [ /PDF ] >> >> stream /Tx BMC EMC endstream endobj 16 0 obj << /Type /Annot /Subtype /Widget /Rect [ 440.17186 120.67644 534.43585 147.7261 ] /F 4 /P 11 0 R /FT /Tx /T (date) /TU (Date.) /DA (/TiRo 10 Tf 0 g) /AP << /N 17 0 R >> /Q 1 >> endobj 17 0 obj << /Length 11 /Subtype /Form /BBox [ 0 0 94.26399 27.04967 ] /Resources << /ProcSet [ /PDF ] >> >> stream /Tx BMC EMC endstream endobj 18 0 obj << /Type /Annot /Subtype /Widget /Rect [ 491.81213 94.44646 543.45241 108.38113 ] /AP << /N 19 0 R /D 20 0 R >> /P 11 0 R /FT /Btn /Ff 65536 /T (Reset) /TU (Press this Reset button to clear the data from all fields.) /A 33 0 R /MK << /BC [ 0 0 0 ] /CA (Reset)/TP 6 >> /H /P /DA (/TiRo 10 Tf 0 g) >> endobj 19 0 obj << /Length 128 /Subtype /Form /BBox [ 0 0 51.64027 13.93468 ] /Resources << /ProcSet [ /PDF /Text ] /Font << /TiRo 21 0 R >> >> >> stream 0 G 1 w 0.5 0.5 50.6403 12.9347 re s q 1 1 49.6403 11.9347 re W n 0 g BT /TiRo 10 Tf 14.7104 3.5672 Td 11.16 TL (Reset) Tj ET Q endstream endobj 20 0 obj << /Length 177 /Subtype /Form /BBox [ 0 0 51.64027 13.93468 ] /Resources << /ProcSet [ /PDF /Text ] /Font << /TiRo 21 0 R >> >> >> stream 0.749 g 0 0 51.6403 13.9347 re f 0 G 1 w 0.5 0.5 50.6403 12.9347 re s q 1 1 49.6403 11.9347 re W n 1 0 0 1 1 -1 cm 0 g BT /TiRo 10 Tf 14.7104 3.5672 Td 11.16 TL (Reset) Tj ET Q endstream endobj 21 0 obj << /Type /Font /Name /TiRo /BaseFont /Times-Roman /Subtype /Type1 /Encoding 22 0 R >> endobj 22 0 obj << /Type /Encoding /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 ] >> endobj 23 0 obj << /ProcSet [ /PDF /Text ] /Font << /TT2 24 0 R /TT4 28 0 R /TT6 29 0 R /TT8 31 0 R >> /ExtGState << /GS1 38 0 R >> >> endobj 24 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 89 /Widths [ 332 0 0 0 0 0 0 0 0 0 0 0 0 0 332 0 0 627 627 627 627 0 0 0 0 0 0 0 0 0 0 0 0 738 627 701 719 572 553 738 719 276 0 0 535 904 719 756 590 0 646 646 627 719 719 996 0 682 ] /Encoding /WinAnsiEncoding /BaseFont /HIINHM+Univers /FontDescriptor 27 0 R >> endobj 25 0 obj << /Type /FontDescriptor /Ascent 955 /CapHeight 687 /Descent -250 /Flags 32 /FontBBox [ -230 -250 984 955 ] /FontName /HIINME+Univers,Bold /ItalicAngle 0 /StemV 142 /FontFile2 37 0 R >> endobj 26 0 obj << /Type /FontDescriptor /Ascent 909 /CapHeight 671 /Descent -250 /Flags 34 /FontBBox [ -162 -250 1085 909 ] /FontName /HIIOAC+CGTimes /ItalicAngle 0 /StemV 104 /XHeight 468 /FontFile2 35 0 R >> endobj 27 0 obj << /Type /FontDescriptor /Ascent 966 /CapHeight 687 /Descent -250 /Flags 32 /FontBBox [ -219 -250 970 966 ] /FontName /HIINHM+Univers /ItalicAngle 0 /StemV 96 /FontFile2 34 0 R >> endobj 28 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 89 /Widths [ 332 0 0 0 0 0 0 0 0 0 0 0 332 332 0 0 627 0 627 0 0 627 627 627 0 0 0 0 0 0 0 0 0 738 627 701 719 572 553 0 719 276 0 0 535 904 719 756 590 0 646 646 627 0 719 0 0 682 ] /Encoding /WinAnsiEncoding /BaseFont /HIINME+Univers,Bold /FontDescriptor 25 0 R >> endobj 29 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 122 /Widths [ 295 0 0 0 0 0 0 0 332 332 0 0 332 332 332 332 498 498 498 498 498 498 0 498 498 498 332 332 0 0 0 0 0 719 627 682 738 627 0 0 0 332 0 0 627 0 738 719 572 0 664 535 627 738 0 940 0 719 0 0 0 0 0 0 0 442 498 442 498 442 332 498 498 276 276 498 276 774 498 498 498 498 369 387 276 498 498 719 498 498 442 ] /Encoding /WinAnsiEncoding /BaseFont /HIIOAC+CGTimes /FontDescriptor 26 0 R >> endobj 30 0 obj << /Length 2573 /Filter /FlateDecode >> stream HW]sJ}Gy }lQb0r!Tj>bĕ=U,ںO>뛰ױƞ:ϡ牴ެ.:Gҳ,Ӵ;}庺EԨ:n³X6妩³ߥ7H7>=6"ѷ7H7ϛ2=Eŭϒ7ϳ0:f谭<ulݴ>X뛺V%LN2}@CwoH i>6!FHQ=FT C4Ay$}<'g:¦mDshO/7ʁx>2óۜHר$}-ݲ< g2t@e8fHڬ~4`Ӑa(-hPc,TUȶ첥ϴ7Qf1N0 PYQL{`l*ک#'!B9[~$,9!D~"q$t>eCc{9C>`'4N`> 7$Mq4xx#"% !fZ<xm2^\Szx<}%`-m2G$rAc BPӄx}{m8}c0]/ 5P}C-bǃjKuG~Q+g_WG@x~+$}UcoͣAaYb&FIx;@HLkBw/n@I VbTyg"%zaa<"hURrD:5O-u1e:, XTíQif+T(2DWHM(! 쳠Z":|f# -d(%gj♜ W9JY\vYCzCŤHy2/}X˴^n͊O,~Dh@Ö_Z[xfQ4|H̓D\ͨ#bfj3NQA]'G_1tm2`%-9drt4QžNֹuj iҧnGE]*NBn+#d;F>%t=}hik4%tr֐ӱ? C4&@et= y:x z*UFvWa{gmzpy0>v@(@^hh{i015lS Fڢ%S`Yxb( |iX\m0>m]oz!+)[ddb ~  "}Nz@r?]fђ~?D ϐlx{G}Ud2_>WŠ'o_Sׅ& Sa ?-Oq%^ar@eƓYXt,^oM뵩?<^Y,:V%0$ p#~m#G |/@79g:tFmv'oO$^$"O:xX"$Fit1PbC'$)p#۲ډ>\ +5nyv2;({& 5'y ۨV͎}Z]ގtL;g1|fbl N90 W͐,sK endstream endobj 31 0 obj << /Type /Font /Subtype /TrueType /FirstChar 32 /LastChar 89 /Widths [ 332 0 0 0 0 0 0 0 332 332 0 0 0 0 332 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 738 0 701 0 572 553 738 719 276 0 0 535 904 719 756 590 0 646 646 627 719 0 0 0 682 ] /Encoding /WinAnsiEncoding /BaseFont /HIIPBD+Univers,Italic /FontDescriptor 32 0 R >> endobj 32 0 obj << /Type /FontDescriptor /Ascent 966 /CapHeight 687 /Descent -250 /Flags 96 /FontBBox [ -229 -250 1086 966 ] /FontName /HIIPBD+Univers,Italic /ItalicAngle -15 /StemV 95.87399 /FontFile2 36 0 R >> endobj 33 0 obj << /Type /Action /S /ResetForm >> endobj 34 0 obj << /Filter /FlateDecode /Length 4376 /Length1 8332 >> stream HV{PTν޻ovXQvY!pYUcQ QATP;& >⻾5uL4hRjQLٚ5m&IC4IvT.u1?w;#";5LFW^*ǂ\uCec|,Qs=b/@~mԆ%Fbωyjō RVWS9;o `?阧5]xvsϪؖD?PQ 7Dʆe ugo|zkskp"]ەt6nZFi#ey y|ߗ%9ĺs&TDZgw~U]ꫬKM.y#-d@aFvZDXm#p[GWN?W8jwjX8'o/783{{5@ lv~ [`OsZPnРJ9IG&z7!7a*R(V퇴Z~~Fˠ{?He/ J} t6!BY%}KW!X6 )7 r0_ExR4Y^Mg{5x|[e}pLB[x31zRxD.-a93??K߯ѐ oA,]}ãJn"^aDMߜAANjWA4`0Q5@τc)luKawna/6{;'rWdsK6ψVۤ/2W-S "/ayb>jcUJ0u~bȣ_(\΃ԁI,\몇NYؕ 6r83=~ ~jj j kļ?u5`3 z&p D\5Ap_5zuΘn٬Vl6dY: [{u-++>r4σc堪nMZ]2L&,i\a*,)\#M՘dD*.9;u P^?6TUϗpĀ.mI"I ߀]'&n/{0u?u,vD_%}v͛7ê,U0=l]V UsYŘ0rs#WX}M\ .KScXmPIs_n1oBF_'x=O V]Vj7vw2K(аK;sßnk(%JJ 4w'iӼ^0%Y4kѼ_긗f]سhcWhk|e\]`3YaHET& gJV_?&@7uA[8#I<"TM0LߝN(ؐ0H|XG1W} ?cC\.+Xy͈ufIlk9dfo?f}-KW^袕VLe7qlNQ`WWgC:|5nGs[Q'*;ܱ?Ez9zlZ\VՆ([k3WIf6+rJ53 cs.t7aZ )#39}eEynKUf3ꜱSyޢVі }ƃQv)ͨ` 2UIIC+E@Xe-\@IfJASe-3p;\ϬCMz0^ǼLZ~A*tkm7 Y)VzI10v2iDzlgz=r"wSOLZ(5y33Tr'>Ϳ3>Idh11!ٕa*X>,(1s#5c%q6ǖ8'=ĸI=e٪vūA>ޱ3&xµ޻;lQ0p6I,I 4IZBG6:Xdɒ~YEԵtLM~)M[-69ҺLZ 5["mu>>i<ϻ`=;(8m[i^cҰtp7ֆ%uru1 ME@,^+ޖ7zSGF˰Q:,pA0xpieYfG5p`\v0Y`"oR]`j )p4㎄R/SU/d~_E8+j@aD+s@sL4ѥ!aJUv8Uf}F"3/+f63_XǢYw<J\,Y.ܬ=x_Si:6G1nhKE4>j' $8r^4r2qKu*CL3f!!H]3 >N&SU(}esb@:z@ioʤ6rO~M#ēN -V;B(Sҕ"s9>͇d[bb%~BJM  N)aC[ǣ{e rHLrIө*Т'Gsf1(p[#̟zg\DYFt#@jYYK*kN7%Ũd@DV'_0v}eY" W$̎T*uW1#&ȗ7өo7? xߟ<=xQ@t;9oK"?{;5ݔݠDyD2 W'\J XL|D5;#il\_y%qYg7[ 4>_Xڴ׸+{g݁ӋCp#謸䉄RP0-Q R[ df8%y$~W~CB3aV0®Tg==ѽICw7'}\& ?uBbގOYVґ\ÌW~XBc{6XYɲ߇tjՉPYgv_@+1Yd.v¼)W ƙ)^ c!yr=2iT&0ֲ ub ⃲_V<PZYjU_*v[Bq3Sʊ@/. X.O>6IOal맺olx+p?p*t^2à(:F8w@VMNBBJd6vΙ:Kgi1DΤ"Q4NRIN|!KBrf12 35PHl(a+5G! [6SQ:Tj khȐ?0" fǢYXL쇿J'S0?I/,1_fT#Q>Fğ0iAgõE u"O~:cQ7p:V_q=_.=F5y֙/*RV ش䦛i?qp{^"2ZltmrZMw+>y>TlR&5{Q)J1Xc o2Xɖ5- }{w VZvmO ^B{~վ̞%h\eP~h7;F!w,'mm[fWmTq#9"M[)+꒯.io4t9SQr` endstream endobj 35 0 obj << /Filter /FlateDecode /Length 11064 /Length1 17932 >> stream HW{lSs+"M;K+@%<4 MmhZU* ԁ ֲiCںP*mqKkW;={ch9;Nka;7V<@*tY5?^lWƕVna&l=Vo\튋DD<h#O ޾ Ow`I^ZvY3_MlX' ؅c5O'jw~KVӖ{f;Rw?k8](͡gi2{We zUrJxQnLO}T)L{%IHa[o&J#8tU9JU,ѽ\n S [@7P/c|! $L*xvY.BWR%C;M5*i5cܠEQ'a^"h/Q)l'( }VEAvh]TN.أw.c4H^x/!ۥĚvk4Q7 7E\E=HCܡ:p\;l/eur= וAo}vm@!u10ĩ9"'."` ֯n3IA^ȾG~/AnGA^\_C.2(S>BZaoN8Cˣڭ~/ Ӏ*@֬= ٳu%cL-cqxǥ!}&LM]Jr+WGrI+m9|;w6zoLo;RU6,cw'*zX> a: $p yp"Ɉ\̟Ut,۲βEmlIm>29W~ sz <6  C Onnf? Y2z=r:ymNUCuPfȁF\>++*>_7)&by޼xgqjpKKjwd1.ꛟ|*vg T6`ʰqes=ܹlܒMy)+ce.gy'vl~`ESgvtn*rS408:Ϸ<dc{<׉[)T:Y&Pșgr$UРzSܧB pn>)A,IcoW7]+23n7L˃&~V rX}y T\m MHSvյ‡!zQO4Jshwb3 1((x311*?* YV=_G{ B)I_I1֨P3{tG:XU;FY$S>w, }.)8Z(p T+έ@QlŽzSw7J/<7v5O="9^<,6 b[HG5)~PMZ>ڷ?`zZKZiTq0hiulTZӊqY"|6eZ1营HsI%p\Ʃi S!ϳح&8t˲#;≓,0ѯֱ;ڍ\򱫱ʱMRV,<-mVSu{,'u~nE m1qO)+0sZ-Bqð. P+!BsØ 覧gz"%3R%3⻤h5vm}xw@<_F|Td)$;/(4e,+XDP +8$3}^.x-7)>3cc_Rwn* ."º)A.[2Vb:$PUJ:Vp/@ag+&B&?O-Ծ[{ͥ_ ΦU O ͒x8IW*?CU P[YfMFn)E8c&>1v:% J.EPl@tFL뜢g ).+qk &ĢDfIp-CQt8W4η~H`F d`⾦7"lkŁֱh. ܈6NW=۷sw&M4>e,xx0ZYbIϸZdW GduR~N(:в,6Nq[!K9뉨~کP"xJe_3M".Yqg7o&E -V9po6g[qWr+?B0?#$>͊*\no *)&PV ;'dTc O͗z0fzk.YY.6ޟj}ų>&cջ`ؠ6ȨhHr~Rbpc$,]3DNH =M_(< L-d9V))hFeԑQ"`WD#T{؝}Umw lQ?hrV+2`2_x005f֮>jwz⠺Y -[X&D@-Pm$ T9äeXvwHE‘)%CH>w̿[6ZO{電i.]0[}`ٮئ3||ow؉\ N$p()P T!*UmT[TڭViݦ"b?V~UBԇ}Jlyyyfv\pOXG0~B$ ,XahVd *ޥޜ);^͗UGMVlYKT [ Y3HGOyw=+Rt78P@m6zNg<}ÄOlz|H:zU_4 siLܐP__hb ~ЎN`xlX^O51 IP6K( ꫁_rh%aC\&R4'GomB:W@.\9 L]ʵIz =1 7dPu: _=A'AOG@:2]葊!Q ML:ai)I[㬃b] b%ttt,6-{b^) tp)i)U-\4'֔&qKcJ|u BʇC32LI.;`]@;FhشȆco6nEO:lfV[zޙqx2|Ak <#Ho6{䮞c[:q'vߩ1\_F/09cJ;",PY-n㰫n#F"-cԱͪX!x[v 8-Ӏ6Lb! ^Kok|nje]cNo YTV]|"Ӻ^rϗ lw@pl&͉6+%u,n' aba.^tWꎵ<`VUSM|{ۣK,]ƢGʈz4~:QX_iɹQiT ~X,FwHtq=iFޓ'CuCbz ZYIsg*B{Z7 IQL -f4;%tQ7%w"pDDLdZ>: d>F A2QX)t5J\?uURY)UaNmSPT8cV7Sq+^ ~һJ kVx-!._?峘AM?=iIb:[J==z'۹\Ȧh͂h·:f@$nĢx5P k`Uh(t:s8pZ.-&5p0Dsy Ŭh5QXZ%jZiBp*ZUTV-uKH0AXD@;"?77#BM<'[X$,ݖ(*Z ;Q|ÐR7)SVk}وO1l>!OHT5! ûlbl $+e5Tn ,H GhbLq{H_&x1sSB=v:\NOzpDlXTǘx,)cB`ZDIIpXnr)Q=|ptqopgM:/m.?{Y4'v_O^LJj/J]>w D sn'bh#"Q K{D_wVOU'RGY9rRrvWxg!z  ܙC.3" hݴnH=FT6m"f#ꉹB ZLpvS B9)/KÈ|$VQŏ3%2yaYzeبP,#5 jqҪAc3 O?~C#ʑo nsФl0"*1z7řAp1̠s8DVN.YوW`FT5kG9ЪlV]2+D4^fBAm71Z{Qlsxwvg<[WӝY!մ~c{tʏn]43˷c]aaKc+|W[l[w9vl_[|$88Nti\t]ۑv4i리镪]WۺKWZڢK&!! @@&h;؎UHp~B"Q2M^!H8D.Vx6O9p^煨M IKO]8moG}0T!{фlGi/ e fR|YܕjXvz?~ܖ5^Y:MRJux%rF\j ĘGBf FSW<gk c_-n |~[;ť M!*M~OtϬLw0 Ҭu|33< \[ Ej+Q1jWCuyV|@NRtu-pP/xz x0ww4;9>_P_9xfB#_ j<<վ(XhSpbfGr:sAѮH<Ўϲ&ug2MwdiԬglO2RlV{>J$MF#I^H$!e +$FZ`X&`R7=4B&`Vɖtɹ0bELvRmwɦϴVR"B+,aKiKiFzGҴѐw;mד[WxSCNrlռ:kxb*磹P,HIyea_# fA^% j 2IF1yX{ .p6dS Bh(阽s^mAmvuU⸙jeg{(8?,Ǫ' ꀞݩ"ds&};>ݘK8vBKϊgxwwA1cюȑ` AbuC-ۤnO3?``,45Jlbc'({( 'U83FD{,r`Ox}F,,dQ@?z}+ rPv:Ta3,BHelþL貰u\ٵ2:?/)wȫPL^@(ɩKQɡk p@2iv9`wue`jhfQDV`9R7 iRU2fk&Pܸ'֔LҔd[ ̰I (]Jb3xY2Z5،4cdF0g1"X(ꐹ~2;qj3JHv <3Sf}oB"}L-P)z%.نRXF;bk'$aR}qY51w6TFya L- YU\/vWvd/[뜷vێfh̩&>ilxtZ͇mlW?TIR9p/"clK7n۹df]D4Rt%yauu7)0CA p8 Ghj,MEVeAi Jރp`t YI6Я#1NG~n7'h/ NJ{1 `\z/1őNW+C߂E(9<`ތP\^]lCHK( 9kRqC4;C|ÙcFiO05J-8z-fyN<?~i@kGk9/\Z3qb_]z VyX͋7)q:C4܍ꝸ =|0"Ǖ J zբ 8h;=v:N8'8ld!,6Uζn-F9oa2j j&մ.a7,֕_87<}|BfW_olwU\2 6dx맿\ C0T羴G~`z)rğpdPH [NtK4ǭ thK^ uCqy{$[5GLPحe=񊩸φv7,I#gUn]cswCѵii %:DN*EM}9`x%ݽ4xܔK;io2ގf-iwe-W[ NUFb!@UTz^oF8KȞ_m]Ub#qIS!MҤIk ZVH 4MTlS"C 6&!2AZ+Q1*@h4A': U01$d?s޳8%t M߹>{ʳ3o.ٵձ)O>5±눻{|̣b<./eX`YfSlvn F3ouf8\`0X 9NQsLݫn/Hnx.l5 c[aZ0Pug2Pd] H ĕ+2 E=Kg [*=hߏ1J?L|18FWnwR*cS^r'\8ĉހvdaS5U[oiQ㭻gf@WYY __@|zcRG w#_0T{=Ҍe_XܾvN"X^%ʐH*@yRd◢J SBċVUDa͋V ) T4JZ nA91.RT4IfҨ.:~2tBTd?3R>  vβhuЩЉJcy7$ q'av+;Z 8%BpEԛhSwߵȒ7]5V endstream endobj 36 0 obj << /Filter /FlateDecode /Length 3857 /Length1 7672 >> stream HW pTW9sn`fI !A H#QD*))JaXja,20M``KRjhA0l6a>w#'A&~;p[ U5u!=YlIwUu j.DyNYp~k"s-U~>cIT1?%O4/߽r"݅Ua+Q*5ODjIxeͼjw >ǚu8ݪͫ[C`?:)3qUnVjS?g?o63Y'#hDPeuPAf۩Ii)b?=]'>i`Jb^{~=%P4ԗb D9X +OEYL {l Ȥ66g/ɝtH,c+ 4jhl#hy r2Nya_5@s0R\`|6}(g@9+vџz2@9TўG1OFs;b=]휉N#-.8I@U?mz 8A_k;5a0o0x~qw/j0xqώ Ra|w,e#\21oн`(fţ#ـr7hPj_R=cQylkJD7D<+WGs,-: /\㦹CPhܾ*u/;WKԚSP+J/pL? נz9Z_8/i0hu?a#oYĵ†b٦h> QA+ˀ%Syg3&''%ʿϗq fYaWddJ)4LRp ,/Ee# נ68bk\u𔊡d9', @^Pkz7|3FP 2/W*QBpx})6#N;|v|Nzr + Ǯxk3K|B~9K|ͳپnoݹf;\r HL$Tn XZ_,T\Rxo‰e ,۟wMAV*́7- 2Kב8\&zH.:m[Y^#AF<#C3*-R^Q[qg/_iEy$<%O4HE!!b߅M'3#3n<@6Y?rD/R6M2srI{ĕl2LS B2*#GD43ɉ2Q23 ).M fXhHq0Sw.Eϛ3/w?W77w.1{3W-zD"kql/n\ʼn>tcKgϵL"GT D!j g^o8y\.X1eYJwHyp{xrDtCxQ*(b`SGV>/l?+v.>p>s_Le'D (eE麺Ux.rdzt`bĄȓyȆ-_;\WLZ.`P8gYF fvHe(<;11ʏ' (c"$VZR<l8inmc>^MAAٯ`g ~-Rf7r,W8UkT&cw*۩s@TG{S:Sީ#fLGrY.t6½GkE"\B:9O:c9s"27ȆHxg5 w0vni} {}hkyxGY4JԚ6mS8}3,Ɍ7l cv v, -<%$ ^e.dr)e]ny6#BbqtyqffA֩䍺/I/%NPw2 "w)SlVgFٍ_QUAxܻ{nmwRv-}[M H*`J) I!H|5b@FEF"?EAAB@:.]J~hb 9n=̜oMWt֫D#ԣeՊe Qb ,c9JQ@n`1܄6H .Ez 3.7߿%n6uS.)i*>SNє!Y%قp E qA Y(xJ LCDRDIqJCc<݇lz>\7yžecǫvÓ'ΡaY #|٣;;l3沮 d=K{} .^u| #aBE F6d~#=I1'Zp$ s [J0Qw`%HT7%)`t/! 'ݗ Xs9mL-ѝ,7%#tj!Α)er%pf 6 3 kߔ(:'G72.Z$LZqh4?}_u!U_訛[X2'!fC_Ψ+@`ǓjXm^IxNp3+w|RK@`qRAbz}IdsEs1!RA ƇvJ*"r>3QM7ݺ [TV9PI>5E]$W ͥI FN@4a+Mk;k󝖙[Ewxeѡ{Xraݤ ;ۮ1) >c6kGMi(`.)e9R;1C9@=E.?x>ZSB)S a:"bqY@tl%}9>Β mJROD(͖Lu0YjYȤ)Ffb粂=\v\i!*l QfYD)KYYO.ɈLCjmUfNQTw[xvvp#TCbP&#Td2$])TlekeWƱȃXf`bX ,@Ί,%Vyj7U9 2^&\9焽-"0E^Fb ,N:E~{I8D=L̛%='W!}$z3@d n9( P\*;?1D *)31Pa*L ݱP nп}od۞A9À.nzsv0:30AkThITIULʙ޺xܚmw dnJ"=鳋a6,Nj&j`!4B5yfC ,U#=7~EzYK}WF,W0 '+1eiл0M~zݧ6$]zcWA#%{Y9 endstream endobj 37 0 obj << /Filter /FlateDecode /Length 4267 /Length1 8188 >> stream HU{T3|߷<\XvatWA5D֨V ("GAQգDmԶѶ$j=j?!iZcc6.jܙs޹#^F M8՟_7BN[_7Hԧmr4-9k ޙ5u-5gC:=D_Ϋ~ǰwV!u2S[Z~1G$>[<,D͘jy@ҟbcQUMKT*9_%OtŮZuĀ VJhίs9o+i<,찷ǙrNXx<zy5ͫ†YȠhl7s8x>">]753Ӕ${#@Q .,ɺ/[~6{JQUǬa^lbSNmOW6e$xb3Gyk]KwS8:mױpJ+gt$CIa֝*ؒ1Q~,hB@Ma´,di5慨EݥkJsƫFMƹƬugWٲ*hxr3+VdnQ򥿟3xϽn\zmI37M-/ -{z2<܉lE>5* 3]zJQ:L}ﰮbR>]qVn֓_DЇA`%$y|I"N8S\|\{MΐnJ^ΚvK}3]aBC_>8(|x+5uͷhд1z>I9,`S˩ elzPYխ,vfӺ#/[:-^{Ыrc=΍H'U(Z]Y:x!~., u9?)gra5GUo_0cϨkF9}){fqwM +WOU1{:TGnf4'$!W{lUw~}ͽ}\V޶zV@ (Эj]B97,clDQd:1ūEnk!j&XzNG{Oa$1{~=~~Z4~ N5Yʂy=󚽕ge~[M8)?ޞue<~~yαGQv?uɮԹG$ʗjx<*0s.fp([E#Q04s+D;q EhlOe9__v[#Nhm'/$oʷc[!Y;L@係ksnVq$bFuC{"`QEiVL3، Q$h|I_k@zQzfC?bCA20: A 34X5s% J~ʚCS֠:i:<=b#o*)7>PK!úҿ՜ҭW7Dzd2 :LO^PT2D,d -#m"v"hK=J2\JSVY򽕷ZVbeŮJ{M'yoX1I|wdb5,D }6> q% ɆSP2s"yY5ɈbAcSSd\nq"ҿZ?Ɔ5!{J% n>,Yv;} 9+.R^͚pd\$JK Ļ(QXҨ8ȅ-iw!+:P@g>/9!#کҲ"<Φo~2ḳ rr_F2s k6rVF_C˟=U_OUV-d~ 9"2O9={?XT=E74D!B"+! X/'X˓ZgQ,357^d,c"#XKFnSGjqG^J ޯdZ;7O^򛗞ు=h-wloź/·zJX{A~Eͻ)?[ݸ.]s>eU\l>a,Awݴ''qG)ոWh -ڻ2^~g?\Opu=UhN&eh}] 2~a_W굽;iӳ~xINմzi'VG}Qڂl0q߼ˋ7p؉JI!v >+|mR;}\VxV)uxZ{A6f ݽS; >Mڨ9lH\{O% endstream endobj 38 0 obj << /Type /ExtGState /SA false /SM 0.02 /TR2 /Default >> endobj 1 0 obj << /Type /Font /Name /ZaDb /BaseFont /ZapfDingbats /Subtype /Type1 >> endobj 2 0 obj << /Type /Font /Name /Helv /BaseFont /Helvetica /Subtype /Type1 /Encoding 22 0 R >> endobj 3 0 obj << /S /D >> endobj 4 0 obj << /Nums [ 0 3 0 R ] >> endobj 5 0 obj << /Type /Pages /Kids [ 11 0 R ] /Count 1 >> endobj 6 0 obj << /CreationDate (D:20040421182046Z) /ModDate (D:20040421142502-04'00') /Producer (Acrobat Distiller 5.0.5 \(Windows\)) /Author () /Creator (PScript5.dll Version 5.2) /Title (DD Form 2005, Privacy Act Statement - Health Care Records, February 1976\ ) >> endobj 7 0 obj << /Type /Metadata /Subtype /XML /Length 1467 >> stream 2004-04-21T18:20:46Z 2004-04-21T14:25:02-04:00 Acrobat Distiller 5.0.5 (Windows) PScript5.dll Version 5.2 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 2004-04-21T18:20:46Z 2004-04-21T14:25:02-04:00 2004-04-21T14:25:02-04:00 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 endstream endobj xref 0 8 0000000000 65535 f 0000034397 00000 n 0000034488 00000 n 0000034594 00000 n 0000034624 00000 n 0000034666 00000 n 0000034731 00000 n 0000035002 00000 n trailer << /Size 8 /ID[<67bf0fdf4d019598a778b2d939c0a619>] >> startxref 173 %%EOF 6 0 obj << /CreationDate (D:20040421182046Z) /ModDate (D:20040421143739-04'00') /Producer (Acrobat Distiller 5.0.5 \(Windows\)) /Author () /Creator (PScript5.dll Version 5.2) /Title (DD Form 2005, Privacy Act Statement - Health Care Records, February 1976\ ) >> endobj 9 0 obj << /Type /Catalog /Pages 5 0 R /Metadata 41 0 R /PageLabels 4 0 R /AcroForm 10 0 R >> endobj 13 0 obj << /Type /Annot /Subtype /Widget /Rect [ 72.13245 118.21738 253.28325 149.36548 ] /DA (/TiRo 10 Tf 0 g) /P 11 0 R /FT /Tx /T (Signature) /TU (Signature of patient or sponsor.) /MK << >> /F 4 >> endobj 41 0 obj << /Type /Metadata /Subtype /XML /Length 1467 >> stream 2004-04-21T18:20:46Z 2004-04-21T14:37:39-04:00 Acrobat Distiller 5.0.5 (Windows) PScript5.dll Version 5.2 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 2004-04-21T18:20:46Z 2004-04-21T14:37:39-04:00 2004-04-21T14:37:39-04:00 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 endstream endobj xref 0 1 0000000000 65535 f 6 1 0000036839 00000 n 9 1 0000037110 00000 n 13 1 0000037218 00000 n 41 1 0000037437 00000 n trailer << /Size 42 /Info 6 0 R /Root 9 0 R /Prev 173 /ID[<67bf0fdf4d019598a778b2d939c0a619>] >> startxref 38989 %%EOF 6 0 obj <> endobj 11 0 obj <>/Font<>/ProcSet[/PDF/Text]>>/Rotate 0/Type/Page>> endobj 41 0 obj <>stream Acrobat Distiller 5.0.5 (Windows) 2004-04-21T18:20:46Z 2018-06-04T10:21:22-04:00 2018-06-04T10:21:22-04:00 PScript5.dll Version 5.2 application/pdf DD Form 2005, Privacy Act Statement - Health Care Records, February 1976 uuid:6f834c22-e159-4456-ad8f-9bb165f532af uuid:935b4d32-9c2d-4904-ae97-000e2becf285 endstream endobj 42 0 obj <> endobj 43 0 obj <>stream HW]sJ}wy[hFߛ'lk0r!Tj>b0 Wd~{$! qn!X3}OE{W;m1?'gJyX\G<6Mh[?|xsYaۺC5Xnx7]Wmn\w~}sݿq>,ax? G?6\>LJiQd6tS{  Wl=(\.O7,[\ f[/κ\YWqM000qL⮍P9۞y5:}Φ1i<˘Mc0]ďldAUVCEH-fb6N㓘] R D HG #~Q HCx%e&1jh QT336߲ĆD}x"/j̳j'7c:iiq8rrvS;WN&za!odEcQU^KS3bba6 `op6BU wȏ$@ K~.SiZNj\ x-G[q\s@J$$ dF4A9 )&$.eRS}є \{9^\XK-?! $% b 9bajH`\PV ☔[ }[є}bLYnBE$L}U'^\ s'/~w 8'K%)slNYTm+pEH[Cj wȺOt3HYDoTu +)LPZIKMLC(l=,h 'J遍yD1riMp[p^S˗ %/gzq z,*o/i`<!6HcOZuEp(,b`jwY< |̎E@ h)Q̾|O+FdRAm9@L{*06PyM~y849H *vt\k*;:&6bUQ e% <+a+7LV.о >꫄)ϊe:h.7|fSR^JLwLW,%EakUs N8{jJPR)Keb!P0)&;79.Ν7p}xjz7CIzmkI5aWnG#'=4NU'\ !fDniГsO&e?LMC =o%ޮ-7hU[ QLeYg0GCWwEu| xi %ISm # V(;*E&+h<‡v:C;;ҵ=G Hcob[:'Yt@Cn|ŚBl"LǬ?iL3-+b}i%A#zx{OtUzmߙvMET'v0{p*aR& h$ط*5%MRzKoS[hB"^;]-*(#Leb^DqzߢsA.^\Ԝf`3Dn0ZCK(0ëpϗ7_]Κbh(&cg- sU|MBK1@FavW_{:hvCkIeNN$ cѯ\yigy#~؇k^)x׃k>֨Ne;^  endstream endobj 44 0 obj [46 0 R] endobj 45 0 obj <>stream H\K0,EQc-P`6^;%څ~Ҝҁ (|ܓcin0ͬlhnеQYәAozb_\-L}i!siv [B(~s ^PY\z3KXQZK==8mw5e$0c6j{(O*X~63Kkk䩗' O@'tPfP2imAmA{.G:p@P*( J!A@ >|*Sz; Laf3SL@gq?iLµk %\kw/yjH̑9#bsOMgqѯR: endstream endobj 46 0 obj <> endobj 47 0 obj <> endobj 48 0 obj <> endobj 49 0 obj <>stream H:\ CA= endstream endobj 50 0 obj <>stream H|UkPY&$i +]Icw)EEPPaYu\y$@x"GA )2玊PSΖ3l٪?_sswn1[ qw)Rʔ`(58{[s m9ڞDь4bnymY+Ʒ(bL6˔@% Xٌ,CVY5D(M^o\re R>P-@G?lS7%&UfM#upx$Aܤ-E751 ߚbĪ5) 3M1\y(q7Yg򉄫JӃQ~ )RY@ E%O8<~<%sSh߽xÆ{C>KKHCכ2=ͽÏ>  nJunݓ"xK;ݧ{j h @|aؿ|vg33 ri Pw`|\u(QUF[7TWCυMG=yRU\^$R#f1/GB8tmX13{6&c)[7vyXFzWKNݬ оm@B ࢿo@4>?ʨ?=v>;~BהkÓD!}pXTbN3O}N/[kH~[pz)ءHB"S̠V=od`d y Va,JW֟6՞Dp92o%0OwT%N_ MIy Q̌)~礄ᦊj]co]+(]FQO(N@Wmqwqy/\'\[ؗ.̹ ðbM2vz ZĠXp ?yXԷ7'DlI 7Ղwq''eC{alB-|RXV 7"RrBK!g$Be߱ڳ0w;b3όRB܅V&qqN[`K^_ofDKgKЍw?<'R'ώm ؕ¼'ҲF7#^?vI2p8wi"E QS"Q5s0@B3]AM\qf]Ѧ kl[v:Nu,Zk4(Ey! y'd @B `7"UdjZuc{Yf ~{hbUC$ڍ1x Fi7Q{4Lq:h|x@jj9;zwPTw 1,1xq5пQ3\Q+Qޢ~[n)delSA},˳ؘoN* QAb_uYgԝr_AQS(Zai&!o=I賂R<_8]=N8iϞQ#A5e.CS7{H+ IOL,.4%o;~mr~M:tK˰>~b3@"=^ .f^ A"AyLlɛEik33XZknכ\5Mfn.{9 inz040ŧ v-H6s+i_ ~P:P#8_CssBl!- >U^c+5Ւ hY-ˍr/h 6iRLfL6%asWpQWa;ow^iu IΥuU՚HTVʐ`.F[_Mg+2$FKjނE YoGZZJށ t1DΔ ԓfgo"O&e<џ4ފ>y)Z'u2B‘irE4O&6kEdN&N@|GF+a>Z d ?bo`X]n/} ca܇O8BW.|pv4{WJBƟ0/^NfX: _\ _yp' > endobj xref 0 1 0000000000 65535 f 6 1 0000039277 00000 n 11 1 0000039531 00000 n 41 11 0000039791 00000 n 0000043373 00000 n 0000043512 00000 n 0000046470 00000 n 0000046495 00000 n 0000046936 00000 n 0000052958 00000 n 0000053027 00000 n 0000053300 00000 n 0000053392 00000 n 0000057115 00000 n trailer <<565135F8F8F9DE4F8958618C2B1F13A2>]/Prev 38989>> startxref 57164 %%EOF