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THIS FORM INTO CONFIRMYOUR AUTHORIZATION TO USE OR DISCLOSEYOUR PROTECTED HEALTH INFORMATION FOR A SPECIAL PURPOSE. I give my authorization to use or disclose my protected dental information as described
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What is this form isto confirmyour?
This form is to confirm your identity.
Who is required to file this form isto confirmyour?
Anyone looking to verify their identity may need to file this form.
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To fill out this form, simply provide the requested information accurately.
What is the purpose of this form isto confirmyour?
The purpose of this form is to verify and confirm your identity.
What information must be reported on this form isto confirmyour?
You must report your name, address, date of birth, and any other requested identifying information.
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