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AUTHORIZATION FOR RELEASE OF INFORMATION TO BE SENT TO OUR PRACTICE (Please print clearly) PATIENT INFORMATION: Patient Name: First Middle Last Social security number Date of birth I, the undersigned,
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Tri-State Medical Group Inc. is a medical group that provides healthcare services in three states.
Tri-State Medical Group Inc. is required to file by healthcare providers operating in multiple states.
To fill out the tri-state medical group inc, the healthcare provider must include detailed information about their operations in each state.
The purpose of tri-state medical group inc is to report on the healthcare provider's activities in three states.
The tri-state medical group inc must include financial information, patient data, and details on services provided.
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