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THIS FORM MUST BE COMPLETED IN ITS ENTIRETY OR IS NOT CONSIDERED A VALID MEDICAL RECORDS REQUESTPatient Name (please print) Date of Birth: Social Security Number: I hereby authorize the release all
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This form is a tax form.
Individuals and businesses with taxable income.
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The purpose of this form is to report income to the government.
Income, deductions, and credits must be reported on this form.
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