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ODESSA/HCA BEHAVIORAL HEALTH CUSTOMER DATA CORE This form is for adults (18+) only. SECTION I Agency: Member ID: Date of Birth (MMDDYYYY): RACE: (1Yes for all that apply; Blank No) White American

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What is this form is for?

This form is for reporting financial information.

Who is required to file this form is for?

Individuals and businesses meeting certain criteria.

How to fill out this form is for?

By providing accurate and detailed financial data.

What is the purpose of this form is for?

To ensure transparency and compliance with regulations.

What information must be reported on this form is for?

Income, expenses, assets, and liabilities.

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