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PATIENT INFORMATION FORM Name: (Last) (First) SSN (Required for Weight Loss Program): Home Address: City: Home Phone: () Best number to reach you:(M.I.) Birth Date: State: Cell Phone: (Sex: (M / F)
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What is no cell provider?
No cell provider is a form that individuals can submit to declare that they do not have a cell phone provider.
Who is required to file no cell provider?
Individuals who do not have a cell phone provider are required to file a no cell provider form.
How to fill out no cell provider?
To fill out a no cell provider form, individuals must provide their personal information and sign the declaration stating that they do not have a cell phone provider.
What is the purpose of no cell provider?
The purpose of the no cell provider form is to declare that an individual does not have a cell phone provider and therefore is exempt from certain requirements.
What information must be reported on no cell provider?
The no cell provider form requires individuals to provide their name, address, and a statement declaring that they do not have a cell phone provider.
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