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2500 Farmington Ave. Farmington NM 87401 PHONE 505 326-PAIN 7246 FAX 505 592-0063 AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Name Include Previous Names DOB SS Address Mailing City/State/Zip Address Physical TO BE RELEASED TO Where information will be sent Four Corners Spine and Pain 2500 Farmington Ave. Mental Health Includes psychological testing Substance Abuse Alcohol/Drug Acquired immune deficiency syndrome AIDS Human immunodeficiency virus HIV infection Authorized Signature Date...
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What is phone 505326-pain 7246?
Phone 505326-pain 7246 is a form used for reporting income related to pain management services.
Who is required to file phone 505326-pain 7246?
Healthcare providers who offer pain management services are required to file phone 505326-pain 7246.
How to fill out phone 505326-pain 7246?
Phone 505326-pain 7246 can be filled out by providing accurate information about the income earned from pain management services.
What is the purpose of phone 505326-pain 7246?
The purpose of phone 505326-pain 7246 is to report income related to pain management services for tax purposes.
What information must be reported on phone 505326-pain 7246?
Phone 505326-pain 7246 requires reporting of all income earned from pain management services, including details of the services provided.
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