This government document is issued by Health Education for use in Harris County, TX
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https://publichealth.harriscountytx.gov/Portals/27/RGWA%20Forms%20August%2012/Service%20Utilization%20Report%20(SUR)%20Non-CPCDMS%20Form.pdf?ver=LYMXDfNGcr4Fcj7Qpxsg9A%3d%3d