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Patient: Member ID: Gender: Age: DOB: PCP: HP: Date of Service: Send completed form to Fax: (714) 5607693 Annual Wellness Visit Form 2014 Subjective: Past Medical History (mark X to confirm and note
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A patient is an individual receiving medical treatment or care.
Healthcare providers and facilities are required to file patient information.
Patient information can be filled out electronically or on paper forms provided by healthcare providers.
The purpose of patient filing is to track medical treatment and care provided to individuals.
Patient information typically includes name, date of birth, medical history, and treatment received.
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