AC19
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[PERSON'S FIRST MIDDLE AND LAST NAME] [NAME OF MEDICAL CARE PROVIDER.......]
SHOW CARD AC-2.
What is (PROVIDER)'s race?
CODE ALL THAT APPLY.
WHITE .................................. 1
BLACK/AFRICAN AMERICAN ................. 2
ASIAN .................................. 3
INDIAN/NATIVE AMERICAN/ALASKA NATIVE ... 4
OTHER PACIFIC ISLANDER ................. 5
SOME OTHER RACE ....................... 91
REF ................................... -7
DK .................................... -8
[Code All That Apply]
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IF CODED '91' (SOME OTHER RACE) ALONE OR IN COMBINATION WITH OTHER CODES, CONTINUE WITH AC19OV
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OTHERWISE, GO TO AC20
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