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315 W. Broadway Mayfield KY 42066 RHEUMATOLOGY REFERRAL FORM Fax 270-247-6033 or 270-251-3571 Today s Date Phone 270-247-3725 Needs by Date Ship to Patient Patient Information Prescriber Information Patient Name Prescriber Name Address City State Zip Home Cell DEA SSN NPI DOB Sex Office State Lic Phone Drug Allergies Other Fax Contact Person INSURANCE INFORMATION Please fax front back copy of Medical Prescription card s if possible Clinical Information Statement Of Medical Necessity...
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What is or 270-251-3571?
The number 270-251-3571 is a specific tax form used for reporting certain information to the IRS.
Who is required to file or 270-251-3571?
Individuals or entities who meet certain criteria set by the IRS are required to file the form 270-251-3571.
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The form 270-251-3571 can be filled out either manually or electronically, following the instructions provided by the IRS.
What is the purpose of or 270-251-3571?
The purpose of form 270-251-3571 is to report specific information to the IRS for tax purposes.
What information must be reported on or 270-251-3571?
Form 270-251-3571 requires the reporting of certain financial and tax-related information as specified by the IRS.
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