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PATIENT AUTHORIZATION TO RELEASE MEDICAL INFORMATION PATIENTS NAME: DATE OF BIRTH: AGE: I authorize the release of personal medical, psychiatric, drug and/or alcohol abuse information and records

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Enter your Social Security Number or Tax Identification Number, if applicable.

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Who needs pw pg 4?

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PW PG 4 is needed by individuals who are required to file federal tax returns. This form is specifically used for reporting certain income thresholds, deductions, and credits.

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