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Limited Patient Authorization for Disclosure of Protected Health InformationForm 7.31Please print all information. Form must be signed and dated each year. Patient Name: Date of Birth:SSN (last four
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The form that must be signed is Form XYZ.
All individuals over the age of 18 are required to file Form XYZ.
Form XYZ can be filled out electronically or submitted in paper form.
The purpose of Form XYZ is to collect important information for tax purposes.
Form XYZ requires information such as name, address, social security number, and income.
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