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FinancialAgreement/RegistrationForm PermissionforTreatment:Permissionisherebygrantedforphysicians, residents, employeesoragentsoftheUSFCollegeofMedicine(USF PhysiciansGroup)(collectively, provider)torenderthepatientnamedbelowsuchmedicalandsurgicaltreatmentasisdeemednecessary.
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CityStateZipEmailAddress refers to the combination of a city, state, zip code, and email address.
Individuals or businesses who need to provide their city, state, zip code, and email address for a specific purpose.
You can fill out the city, state, zip code, and email address fields either online, on a form, or through a digital platform.
The purpose of providing city, state, zip code, and email address is to accurately identify a location and contact an individual or business.
You must report the correct city, state, zip code, and email address that corresponds to your location and contact details.
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