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Authorization for Release of Medical Information Patient Name Date of Birth City, ST, Zip Phone Numerate of Records Request: I, the undersigned, authorize/request the below named medical office/doctor
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How to fill out city st zipphone number

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How to fill out city st zipphone number

01
Start by writing the city name of the address.
02
Next, write the state abbreviation for the address.
03
After the state, write the zip code for the address.
04
Finally, write the phone number, including the area code.

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What is City, ST, ZipPhone Number Form?

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Instructions for the City, ST, ZipPhone Number form

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