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1303 Fifth St., Suite 202 Colville, IA 52241 phone 319.358.6520 fax 319.538.0093 Authorization to Disclose Protected Health Information Patients Full Name Date of Birth Psychologist I, the undersigned

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How to fill out 1303 Fifth St:

1. Start by completing the street address section. Write "1303" in the appropriate box to provide the house or building number.
2. Move on to the "Fifth St" line and enter "Fifth St" or simply "5th St" as the street name.
3. Fill out complementary information if required. Depending on the form or document, you may need to provide additional details such as apartment number, floor, or suite. If applicable, ensure that this information is correctly filled out.
4. Double-check the accuracy of the information provided. Review that the address is written accurately, without any misspellings or mistakes.
5. After confirming that all the necessary details are provided and accurate, proceed to submit or use the completed form as required.

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4. Local authorities or government agencies that may require this address for administrative or compliance reasons.
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To fill out 1303 Fifth St, individuals or entities must provide all the requested information accurately and submit the form by the deadline.

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