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-7008S%20Administracion%20de%20Medicamentos%20por%20el%20Proveedor%20de%20Cuidado%20Infantil%20Legalmente%20Exento.doc