This government document is issued by Office of Children and Family Services for use in New York
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https://ocfs.ny.gov/main/Forms/Day_Care/OCFS-LDSS-7000S%20PLAN%20DE%20SALUD%20PARA%20LA%20ADMINISTRACION%20DE%20MEDICAMENTOS%20PARA%20PROVEEDORES%20LEGALMENTE%20EXENTOS.dot