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PATIENTDEMOGRAPHICINFORMATION (Greasepaint)AreyouasurvivoroftheOctober1,2017,Route91tragedy?:Yes No TodaysDate: Provider(s):PATIENTINFORMATION PatientsLastName: First: Middle: SSN: Isthisyourlegalname?
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What is providers?
Providers are individuals or entities that offer goods or services.
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Any individual or entity that provides goods or services to others may be required to file a providers report.
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The purpose of providers is to track and report information about individuals or entities that provide goods or services.
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Information such as name, address, contact information, and details of the goods or services provided may need to be reported on providers.
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