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Medical Record # Patient Information Full Name Date of Birth Address City Day Phone # State & Zip Cell # Release To Name Address City Phone # Fax # Release Form/Delivery I would like my copies to
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State amp zip refers to the state abbreviation and zip code of an individual or business address.
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Individuals or businesses who are required to report their address information for tax or legal purposes.
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The information required on state amp zip typically includes the state abbreviation (e.g. CA for California) and the zip code (e.g. 90210).
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