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!, Corrected Rural “OD I 'rt ......, Care (“IE, REGISTRATION Date : Patient Information Patient Primary Care Physician:. How did you hear about us? Middle: First: Patient Last Name: If Minor,
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Urlrnl quotod i039rt care is a tax form used to report information about health coverage provided to employees and to report offers of coverage to the IRS.
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Information such as the employer's name, address, employer identification number (EIN), and details about the health coverage offered must be reported on urlrnl quotod i039rt care.
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