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Ability Health Services & Rehabilitation, LP Patient History Form Patient Name: D.O.B.: SSN#: Email Address: Age: Cell/Phone # Sex: Male FemaleMarital Status (please circle): Single Married DivorcedReligion:

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Ability Health Services Amp is a form used to report health services provided by healthcare providers.

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Information such as patient demographics, type of service provided, date of service, and billing information must be reported on Ability Health Services Amp.

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