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Name (as it appears on insurance card): Date of Birth: Age: Gender (circle one): Male / Beale Street Address: City: State: Zip Code: Family Doctor: Method of payment: Cash / Insurance (please provide
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What is Name (as it appears on insurance card): Form?

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Instructions for the form Name (as it appears on insurance card):

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Name as it appears is the legal name of an individual or entity as it is written on official documents.
Any individual or entity that is required to provide their legal name in official documents is required to file name as it appears.
Name as it appears should be filled out exactly as it is written on official documents, without any abbreviations or alterations.
The purpose of name as it appears is to ensure accurate identification and documentation of individuals or entities.
The information reported on name as it appears should include the full legal name of the individual or entity.
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