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AUTHORIZATION TO DISCLOSE PROTECTED HEALTH INFORMATION **Please refer to instructions on reverse side.****Printed Client Name:**Address:**City: **State: **Zip Code: **Date of Birth:**Telephone Number:()

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How to fill out citystatezipcode

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What is citystatezipcode?

Citystatezipcode is a field where the city, state, and zip code of a location are entered.

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Anyone who is filling out a form or document that requires the city, state, and zip code of a location will need to fill out the citystatezipcode field.

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To fill out the citystatezipcode field, simply enter the name of the city, the state abbreviation, and the zip code of the location in the designated spaces.

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The information required to be reported on citystatezipcode includes the city name, state abbreviation, and zip code of a location.

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