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I authorize my provider to furnish complete information to my health insurance company regarding services rendered and hereby claim the amount of indemnity specified in my contract with my health insurance company. 6400 Thornberry Ct Suite 620 Mason OH 45040 Ph 513-229-8386 Fx 513-229-8385 Patient Information Client Name First MI Last Today s Date Address City State Zip Date of Birth MM/DD/YYYY SSN Home Work Cell Employer/School Marital Status Single Married Divorced Widowed Responsible...
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Chapter 1 Harness form is a form used for reporting specific information related to harness racing.
Owners, trainers, and drivers participating in harness racing events are required to file chapter 1 harness form.
Chapter 1 Harness form can be filled out by providing accurate information about the horse, race details, and other relevant information as required.
The purpose of chapter 1 harness form is to maintain transparency in harness racing events and ensure compliance with regulations.
Information such as horse details, race schedule, trainer details, and owner information must be reported on chapter 1 harness form.
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