HHSC Policies and Procedures

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Administration  –  Board of Directors  –  Compliance  –  Environment of Care  –  Finance  –  Health Information Management  –  Human Resources  –  Information Technology  –  Internal Auditor  –  Operations  –  Patient Care  –  Purchasing  –  Research  –  Telemedicine

AdministrationEffective Date
ADM 0001 – Records Release and Copying ChargesRedesignated to ADM 0038A
ADM 0002A – Compensation for Temporary Assignment to Exempt Positions6/19/14
ADM 0003 – Dues for Professional Business Organizations11/13/13
ADM 0004 – Gifts to Board MembersSee BOD 0004A
ADM 0005A – Travel by Employees Inter-Island and Out of State11/21/13
ADM 0005B – Procedure
ADM 0006 – Use of HHSC State Vehicles06/01/00
ADM 0007 – Corporate Policy on Compliance with Antitrust Laws09/20/00
ADM 0008 – Corporate Policy on Responding to Government Agencies09/20/00
ADM 0009 – Corporate Policy on Credentialing and Background Checks11/30/00
ADM 0010 – Basic Life Support Training10/04/02
ADM 0011 – Reporting and Processing Long Term Care Quality Indicators to the Quality Council12/19/01
ADM 0012 – DonationsSuperseded by CMP 0013
ADM 0013 – Employee Housing and Rental Policy11/17/05
ADM 0014 – Employed and Contracted Practitioner Credentialing04/17/08
ADM 0015 – Physician EmploymentRedesignated as HR 0015
ADM 0016 – HHSC Travel Policy for Corporate and Regional Board Member04/14/11
ADM 0017 – Credentialing for Interpretive Reading of Off-Site Services04/17/08
ADM 0018 – Educational Assistance and Tuition Reimbursement01/25/07
ADM 0019A – Adoption of Corporate-Wide Policies10/13/11
ADM 0019B – Procedure
ADM 0020 – Transfer of Custodial Control to Regional BoardsRescinded
ADM 0021 – Expedited Credentialing04/17/08
ADM 0022 – Credentialing Requirements04/17/08
ADM 0023 – (Eliminated)N/A
ADM 0024 – InsurancePending
ADM 0025 – Attorney Billing Guidelines for Non-Insurance Matters11/13/08
ADM 0026A – Retention of Outside Counsel04/19/12
ADM 0027A – Risk Management Policy09/27/18
ADM 0027B – Risk Management Plan09/27/18
ADM 0028 – Settlement PolicySuperseded by ADM 0028A
ADM 0028A – Claims Management and Settlement Policy04/19/12
ADM 0028B – Procedure
ADM 0030A – Risk Management PlanSuperseded by ADM 0027B
ADM 0031 – Conflict Resolution08/12/10
ADM 0032 – Workplace Disruptive Behavior No-Tolerance08/12/10
ADM 0033 – Tobacco Free Campus04/27/17
ADM 0034A – Person Authorized to Accept Service of Process06/20/13
ADM 0034B – Procedure
ADM 0035A – Preservation of Information in Litigation or Anticipation of Litigation06/20/13
ADM 0035B – Procedure
ADM 0036A – Driving Vehicles for HHSC Business02/20/14
ADM 0037A – HIPAA Records Release and Schedule of Charges07/18/16
ADM 0038A – Records Release and Schedule of Charges07/18/16
ADM 0045A – Legal Health Record08/25/16

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Board of DirectorsEffective Date
BOD 0001A – Procedural Rules for the HHSC Board of Directors Meetings05/22/14
BOD 0004A – Gifts to Board Members06/19/14

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ComplianceEffective Date
CMP 0001A – HHSC Corporate Compliance Program12/09/10
CMP 002A – Audit & Compliance Comm, Corp Compliance Comm, Chief CPO10/13/11
CMP 002B – Procedure
CMP 003A – Regional Compliance Officer Responsibilities10/13/11
CMP 003B – Procedure
CMP 004A – Compliance Hotline & Other Internal Methods of Reporting Non-Compliance10/13/11
CMP 004B – Procedure
CMP 0005 – Code of ConductSuperseded by CMP 0001A
CMP 006A – Compliance Disclosure Program10/13/11
CMP 006B – Procedure
CMP 007A – Corporate Policy on Education and Training10/13/11
CMP 007B – Procedure
CMP 008A – Retention of Records10/13/11
CMP 008B – Procedure
CMP 009A – Compliance Investigations10/13/11
CMP 009B – Procedure
CMP 010A – Compliance Reporting Standards10/13/11
CMP 010B – Procedure
CMP 0011 – False Claims Acts and Whistleblower’s Protection Act12/20/06
CMP 0012 – HHSC Corporate Arrangements Inclusive of Hilo Medical CenterRescinded
CMP 0013 – Use of State Resources in Support of Community Charities; Donations Prohibited6/18/09
CMP 0014A – HIPAA Breach Notification09/19/13
CMP 0015A – Identity Theft Prevention Program Policy (“Red Flag”)12/19/13
CMP 015B – Procedure
CMP 0016A – Conflict of Interest10/13/11
CMP 0016B – Procedure
CMP 0017A – Policy for Use of Social Networking and Other Electronic Media10/13/11
CMP 0017B – Procedure
CMP 0018 – Non-Retaliation and Non-Retribution02/11/11
CMP 0019A – Minimum Necessary09/19/13
CMP 020A – HIPAA Privacy and Security Policy and Practices Requirements09/20/12
CMP 021A – Privacy and Security Council09/20/12
CMP 0022 – Non-Discrimination Policy for Language AccessSuperceded by CMP 0101A
CMP 0023A – Grievance Process for Alleged Discrimination for Language Access06/20/13
CMP 023B – Procedure
CMP 0024A – Use and Disclosure of PHI Subject to the Treatment, Payment and Health Care Operations Exception09/19/13
CMP 0025A – HIPAA Complaint09/19/13
CMP 0026A – Sanctions09/19/13
CMP 0027A – HIPAA Training09/19/13
CMP 0028A – Notice of Privacy Practices09/19/13
CMP 0029A – HIPAA Authorizations for Use and Disclosure of Protected Health Information09/19/13
CMP 0029B – Procedure
CMP 0030A – HIPAA Avert Threat Health and Safety Use Disclosure09/19/13
CMP 0031A – HIPAA Business Associate Disclosure10/17/13
CMP 0032A – HIPAA Decedents Use and Disclosure09/19/13
CMP 0032B – Procedure
CMP 0033A – HIPAA De-Identification and Limited Data Use Disclosure09/19/13
CMP 0034A – HIPAA Release of Facility Directory Information to Public and Press09/19/13
CMP 0035A – HIPAA Educational Purposes Use and Disclosure09/19/13
CMP 0036A – HIPAA Government Functions Use and Disclosure09/19/13
CMP 0037A – HIPAA Health Oversight Activities Use and Disclosure09/19/13
CMP 0038A – HIPAA Judicial and Administrative Proceedings Use and Disclosure09/19/13
CMP 0039A – HIPAA Cadaveric Organ Donation Use and Disclosure09/19/13
CMP 0040A – HIPAA Patient Right to Accounting of Disclosures09/19/13
CMP 0041A – HIPAA Individual Right to Request Amendment09/19/13
CMP 0042A – HIPAA Patient Right to Confidential Communications09/19/13
CMP 0043A – HIPAA Patient Right to Request Restrictions09/19/13
CMP 0044A – HIPAA Personal Representatives09/19/13
CMP 0045A – HIPAA Public Health Activities Disclosures09/19/13
CMP 0046A – HIPAA Research Purposes Use and Disclosure09/19/13
CMP 0047A – HIPAA Verification Prior to Disclosure09/19/13
CMP 0048A – HIPAA Victims of Abuse or Neglect Disclosures09/19/13
CMP 0049A – HIPAA Patient Right to Access and Obtain Copies of Designated Record Set09/19/13
CMP 0050A – HIPAA Release of Information for Law Enforcement Purposes09/19/13
CMP 0051A – HIPAA Use and Disclosure for Involvement in Individual’s Care09/19/13
CMP 0052A – HIPAA Departmental Release of Protected Health Information09/19/13
CMP 0053A – Exclusions and Sanctions Policy10/17/13
CMP 0053B – Procedure
CMP 0054A – Providing Electronic Protected Health Information (ePHI) to Patients10/17/13
CMP 0055A – Fundraising Communications09/19/13
CMP 0056A – Workforce Member Access to Protected Health Information (PHI)02/22/18
CMP 0057A – Texting Patient Information Among Health Care Providers and Staff Members07/26/18
CMP 0057B – Procedure07/26/18
CMP 0100A – Nondiscrimination (General)07/25/19
CMP 0100B – Procedure10/27/16
CMP 0101A – Nondiscrimination Policy for Language Access07/25/19

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Environment of CareEffective Date
EOC 0001 – Laboratory Packaging and Shipping of Dangerous Goods01/12/00
EOC 0002 – Corporate Policy on Medical Waste11/01/00
EOC 0003 – Single Use Devices02/20/14

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FinanceEffective Date
FIN 0001 – Protocol Fund07/11/02
FIN 0002 – Corporate Policy on Financial Agreements with Physicians and Other Providers07/01/04
FIN 0003 – Corporate Policy on Vendor RelationshipsRescinded
FIN 0004 – Corporate Policy on Financial Arrangements with Referral Sources Other than Physicians09/22/00
FIN 0005 – Invoice Approval for PaymentPending
FIN 0006 – Critical Access Hospitals11/13/08
FIN 0007 – Notice of Medicare Non-Coverage in a Skilled Nursing Facility12/05/01
FIN 0008 – Notice of Medicare Non-Coverage in a Skilled Nursing Facility – 65C Plus12/05/01
FIN 0009 – Debtor Tax Refund Setoff02/22/18
FIN 0010 – Prompt Pay Discounts of Account Receivables09/08/05
FIN 0011 – Cash Management08/21/08
FIN 0012 – Payroll Funding08/21/08
FIN 0013 – Operational Budgeting08/21/08
FIN 0014 – Governmental Budgeting08/21/08
FIN 0015 – Capital Budgeting08/21/08
FIN 0016 – Municipal Lease Financing11/13/08
FIN 0017 – Debt Management11/13/08
FIN 0018 – Investments11/13/08
FIN 0019 – Accounts Receivable Valuation04/09/09
FIN 0020 – Funds Allocation11/13/08
FIN 0021 – Operating Lease Policy11/13/08
FIN 0022 – Short Term Debt and Revolving Lines of Credit11/13/08
FIN 0023 – Third Party Payer Contracting11/13/08
FIN 0024 – Revenue Cycle Management11/13/08
FIN 0025 – Revenue Cycle Quality Management Reporting11/13/08
FIN 0026 – Charge Description Master Policy01/29/09
FIN 0027 – Disposal of Real Property04/09/09
FIN 0028 – Real Estate Leases01/29/09
FIN 0029 – Accounting01/29/09
FIN 0030 – Acquisition and Disposal of Assets04/09/09
FIN 0031 – Banking01/29/09
FIN 0032 – Preparing Submitting and Managing Cost Reports01/29/09
FIN 0033 – Region to Region Loans01/29/09
FIN 0034 – Submission of Project and Funding Requests to FISAC Policy04/09/09
FIN 0100A – Medicare Outpatient Observation Notice – MOON04/27/17
FIN 0501 – Referred Laboratory Testing09/15/00
FIN 0502 – Laboratory Reflex Orders 09/15/00
FIN 0503 – Laboratory Stat Fees and Call Backs 09/15/00
FIN 0504 – Laboratory Anatomical and Surgical Pathology Services 09/15/00
FIN 0505 – Calculated Laboratory Lists 09/15/00
FIN 0506 – Advance Beneficiary Notice 09/15/00
FIN 0507 – Laboratory Standing Orders 09/15/00
FIN 0508 – Laboratory Services in Skilled Nursing Facilities 09/15/00
FIN 0509 – Laboratory Patient Records 09/15/00
FIN 0510 – Laboratory Custom Profiles 09/15/00
FIN 0511 – Processing Credit Balances and Potential Overpayments02/20/14
FIN 0512 – Laboratory Specimen Collection Fees 09/15/00
FIN 0513 – Laboratory Urinalysis Procedure 09/15/00
FIN 0514 – Outpatient Services and Medicare Three Day Window – 72 Hour Rule 09/15/00
FIN 0515 – Laboratory Medical Necessity 09/15/00
FIN 0516 – Critical Pathway Laboratory Orders 09/15/00
FIN 0517 – Laboratory Handling Charges 09/15/00
FIN 0518 – Laboratory Hematology Procedures 09/15/00
FIN 0519 – Laboratory Organ and Disease Panels09/15/00
FIN 0520 – Charity Care 06/01/04
FIN 0521 – Small Balance Write-Offs of Accounts Receivable 02/10/99
FIN 0522 – Write-Off of Patient Accounts Receivable Greater Than 365 Days 02/10/99
FIN 0523 – Unlisted Laboratory Procedure Codes 09/22/00
FIN 0524 – Outpatient Laboratory Test Orders 09/26/00
FIN 0525 – Changing ICD-0 CPT-4 and HCPCS Codes 11/15/00
FIN 0526 – Tracking Rejected Claims12/06/01
FIN 0527 – Medical Supply and Equipment Billing Policy 01/01/07
FIN 1001 – Standardized Work Paper Package 12/13/99
FIN 1002 -Cost Report Review12/13/99
FIN 1003 – Representation Submission 12/13/99
FIN 1004 – Protested Items 12/13/99
FIN 1005 – Review for Non-Allowable Costs 12/13/99
FIN 1006 – Fiscal Intermediary Audits 12/13/99
FIN 1007 – Cost Report Errors 12/13/99
FIN 1008 – Disclosure-Transmittal Letter 12/13/99
FIN 1009 – Cost Report Work Paper Documentation 12/13/99
FIN 1010A – Bad Debt ProcessingPending
FIN 1011A – Balancing IssuesPending
FIN 1012A – Charge Reconciliation – Charge Error WorklistPending
FIN 1013A – Small BalancesPending
FIN 1014A – Managing DenialsPending
FIN 1015A – Eligibility ResponsePending
FIN 1016A – Late Charge ManagementPending
FIN 1017A – Medical NecessityPending
FIN 1018A – Payment ArrangementsPending
FIN 1019A – Payment VariancePending
FIN 1020A – Remittance ProcessingPending
FIN 1021A – Change Patient StatusPending
FIN 1022A – Referring Non-Medical StaffPending
FIN 1023A – Balancing Guarantor PaymentsPending
FIN 1024A – Contractual AllowancesPending
FIN 1025A – Managing Duplicate Persons and Medical Record NumberPending
FIN 1026A – Health Information Management BalancingPending
FIN 1027A – Updating and Changing the Insurance Policy Effective DatePending
FIN P001 – HHSC General Payroll Policy 11/13/08
FIN P002 – HHSC General Payroll Info and Pay Dates 11/13/08

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Health Information ManagementEffective Date
HIM 0001A – Administrative Closure of Incomplete Medical Records10/27/16
HIM 1002A – Medical Records:  Coding and Documentation for Outpatient Services10/25/18
HIM 1002B – Procedure10/25/18
HIM 1003A – Medical Records:  Coding and Documentation for Inpatient Services10/25/18
HIM 1003B – Procedure10/25/18
HIM 1010A – Medical Records:  Query Policy10/25/18
HIM 1010B – Procedure10/25/18

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Human ResourcesEffective Date
HR 0001A – Equal Employment Opportunity11/21/13
HR 0001B – Procedure
HR 0002A – Individuals with Disabilities11/21/13
HR 0002B – Procedure
HR 0003A – Non-Harassment Policy11/21/13
HR 0003B – Procedure
HR 0004 – Workplace Violence/Abuse Non-Tolerance08/10/00
HR 0005 – Relocation Assistance Policy01/25/07
HR 0006 – Personnel System General Policy09/13/07
HR 0007A – Exempt Excluded Compensation Policy and Compensation Administration Manual06/12/08
HR 0008 – Placement of Employees who are Disabled by Work-Related Injury or Illness Involving Environmental Restrictions 04/17/08
HR 0009 – Return to Work Priority Procedures 04/17/08
HR 0010 – Protection of Personnel Information Program05/13/08
HR 0011 – Oversight of Employees04/17/08
HR 0012A – Family Leave 09/27/18
HR 0013 – Standards of Dress Grooming and Related Behaviors 06/12/08
HR 0014 – Workers Compensation Stipulation and Settlement Agreement and Orders 01/29/09
HR 0015A – Physician Employment Policy10/13/11
HR 0015B – Procedure
HR 0016 – Alcohol and Controlled Substances Testing Program for Exempt Excluded EmployeesRescinded
HR 0017 – Outside Employment08/12/10
HR 0019A – Negotiation of Memorandums of Understanding and Supplemental Agreements on Subjects of Collective Bargaining 06/20/13
HR 0019B – Procedure
HR 0020A – Telecommuting Program 05/22/14
HR 0020B – Procedure
HR 0021A – Break Time for Nursing Mothers – Act 249 – 2013 Regular Session and Fair Labor Standards Act06/19/14
HR 0021B – Procedure
HR 0023A – Health Care Personnel Influenza Vaccination Policy04/27/17

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Information TechnologyEffective Date
For Authorized Users Only: Click here to access our IT Policies & ProceduresN/A

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Internal AuditorEffective Date
IA 001A – Internal Audit Function Charter10/13/11

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OperationsEffective Date
OPN 0001 – Creation of Business Ventures by Regional System Boards08/21/08

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Patient CareEffective Date
PAT 0001 – Hospital Patients Rights Notice and Grievance Procedure08/01/02
PAT 0002 – Anatomical Donation Policy 02/20/14
PAT 0003 – Emergency Care Transfers – COBRA 09/15/00
PAT 0004 – Corporate Policy on Confidential Patient Information 12/06/01
PAT 0005 – Determination and Documentation of Brain Death 04/12/01
PAT 0006 – Patient Discharge Policy 05/10/01
PAT 0007 – Informed Consent for Treatment or Procedures to Induce Abortions in Minors 01/14/02
PAT 0008 – Corporate Policy on Do Not Resuscitate Orders 12/05/01
PAT 0009 – Percutaneous Exposure Control Pain 10/04/02
PAT 0010 – Reporting Blood and Urine Alcohol and Drug Contents of Persons Involved in a Vehicle CollisionRefer to CMP 0050A
PAT 0011 – Patient Safety Program 07/01/01
PAT 0012A – Disclosure of Unanticipated Outcomes 08/01/02
PAT 0012B – Procedure
PAT 0013A – HHSC System Quality Structure06/25/15
PAT 1001 – Medical Records – 72 Hour Window Rule09/15/00
PAT 1002A – Medical Records – Coding and Documentation for Outpatient Services01/22/15
PAT 1002B – Procedure
PAT 1003A – Medical Records – Coding and Documentation for Inpatient Services 01/22/15
PAT 1003B – Procedure
PAT 1004 – Medical Records – Coding Orientation and Training Continuing Education 09/15/00
PAT 1005 – Medical Records – Coding References and Tools 09/15/00
PAT 1006 – Medical Records – Skilled Nursing Facilities – Units 09/15/00
PAT 1007 – Advanced Directive Procedure 01/04/02
PAT 1008A – HHSC Hand Hygiene Policy 08/16/12
PAT 1008B – Procedure
PAT 1009A – Computerized Provider Order Entry – CPOE 10/17/13
PAT 1009B – Procedure
PAT 1010A – Medical Records Query Policy 03/19/15
PAT 1010B – Procedure

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PurchasingEffective Date
PUR 0001A – Designation of Procurement Responsibilities to the HHSC and Regional Facilities06/20/13
PUR 0001B – Procedure
PUR 0002 – Corporate Office Procurement Dollar Thresholds – Quick Reference 07/21/10
PUR 0003 – Corporate Office Competitive Sealed Bid Process – IFB 07/21/10
PUR 0004 – Corporate Office Emergency Procurements 10/01/07
PUR 0005 – Corporate Policy Competitive Sealed Proposals07/21/10
PUR 0006 – Authority to Procure Personal Services 10/01/07
PUR 0007 – Contracts 10/01/07
PUR 0008 – Construction and Capital Improvement Projects 10/01/07
PUR 0009 – Corporate Office Material and Equipment Inventory and Disposal 10/01/07
PUR 0010 – Procurement Reporting to HHSC Board of Directors04/17/08
PUR 0011 – Oral ProposalsRescinded
PUR 0012 – Capital Equipment Purchase Review by Materials and Contract Management Team 10/01/07
PUR 0013 – Standards of Conduct Applicable to HHSCRescinded
PUR 0014 – Legal Review of RFP – IFB and Contracts 10/01/07
PUR 0015 – Contract Technical Representative Duties 10/01/07
PUR 0016 – Corporate System-Wide Contracts – Sole Source Procurement 07/21/10
PUR 0017 – Corporate and System-Wide Contracts – Exempt Procurement 10/01/07
PUR 0018 – Procurement Protests for Chapter 103D Purchases10/01/07
PUR 0019 – Requesting Purchasing and Acquisition Assistance from Corporate Contract Management 10/01/07
PUR 0020 – Medical Staff Review of Patient Services Contracts 11/01/06
PUR 0021 – Release of Contract and Procurement Information 10/01/07
PUR 0022 – Vendor Visitation and Interaction Rules 11/01/06
PUR 0023 – Authority to Procure Professional Services 10/01/07
PUR 0024 – Procurement Violations 10/01/07
PUR 0025 – Requesting Review and Approval of Group Purchasing Organization Agreements 11/13/08
PUR 0026 – Small Purchases – Including Electronic Procurements 07/21/10
PUR 0027A – Fleet Vehicle Inventory and Disposal10/30/14
PUR 0027B – Procedure

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ResearchEffective Date
RES 0001 – Quality: Corporate Institutional Review Board PolicySuperseded
RES 001A – Corporate Institutional Review Board Policy08/16/12

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TelemedicineEffective Date
TEL 0001 – Telemedicine Policy 02/12/02
TEL 0002 – Patient Rights and Responsibilities During Use of Telemedicine – Telehealth Consultations11/10/99
TEL 0003 – Grand Rounds12/13/99
TEL 0004 – Scheduling a Telemedicine Consultation12/13/99
TEL 0005 – Emergency Telemedicine Consultations12/13/99
TEL 0006 – Telemedicine Electronic Signature Policy12/13/99
TEL 0007 – Failure of Telemedicine Equipment12/13/99
TEL 0008 – Scope of Service – Telemedicine01/11/00
TEL 0009 – Priority of the Telemedicine Workstation and/or Video Conference Equipment and Transmission01/11/00
TEL 0010 – Telemedicine Workstation Orientation for Health Care Providers 01/11/00
TEL 0011 – Telemedicine Operational Satisfaction Survey01/11/00
TEL 0012 – Telemedicine Consultant Satisfaction Survey01/11/00
TEL 0013 – Telemedicine Provider Satisfaction Survey01/11/00
TEL 0014 – Telemedicine Patient Satisfaction Survey01/11/00
TEL 0015 – Use of the Vidar Scanner for Sending TeleRadiological Images – Surescan10/17/03
TEL 0016 – How to Turn On and Shut Down the Telemedicine System01/09/01
TEL 0017 – Standardized Date and Time Format in Telemedicine SystemPending
TEL 0018 – Changing Your Password in the Medreach Telemedicine Software04/24/01
TEL 0019 – Administrative Use of HHSC Video Teleconferencing System by Outside Agencies10/15/03
TEL 0020 – Project Request Form (PRF)Pending
TEL 0021 – Administrative Use of HHSC Video Teleconferencing System10/15/03

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