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R E V IE W O F SYSTEM S Please print forms and mail or fax to our office. Patient NameDOBDateReason For Visit REV I EW O F SYSTEMS Do you CURRENTLY have any problems related to the following systems?

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r e v ie stands for Report of Foreign Bank and Financial Accounts. It is a form required by the IRS to report foreign financial accounts.

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U.S. persons who have a financial interest in or signature authority over foreign financial accounts with an aggregate value exceeding $10,000 at any time during the calendar year are required to file r e v ie.

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r e v ie can be filled out electronically on the Financial Crimes Enforcement Network (FinCEN) website or by paper form, FinCEN Form 114. It requires information about the account holder, financial institution, and account details.

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r e v ie requires the reporting of the account holder's name, address, account number, the financial institution's name and address, and the maximum value of the account during the year.

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