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BIRTH CERTIFICATE/PATERNITY PAPERS AFFIDAVIT 5. SOCIAL SECURTIY CARD To verify social security number 6. ANY FALSIFICATION OF ANY INFORMATION MAY BE REASON FOR DENIAL FOR SERVICES OR ELIGIBILITY. Patients Signature/Parent or Legal Guardian Date Patient must be 18 years of age or older to be seen for medical appointments unless accompanied by a parent or an adult. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Rapid City IHS Service Unit Acknowledgement of Receipt of IHS Notice...
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