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AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION EMPLOYEE: Name: (Please Print)Social Security Number: Date of Birth: PATIENT (if different): Name: (Please Print)Social Security Number: Date of Birth:
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To fill out the social security number and date of birth, follow these steps:
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Locate the fields asking for social security number and date of birth on the form or application.
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Enter your nine-digit social security number in the designated field. Make sure to enter it without any dashes or spaces.
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Enter your date of birth in the prescribed format, which is typically month/day/year. For example, if your birthday is on January 1, 1990, you would enter it as 01/01/1990.
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The Social Security Number (SSN) is a unique identifier assigned by the U.S. government to track individuals for Social Security benefits and taxation purposes.
All U.S. citizens and eligible residents who earn income, including employees and self-employed individuals, are required to file for a Social Security Number.
To fill out the Social Security Number application, complete Form SS-5, provide necessary identification documents, and submit it to the Social Security Administration, either in person or via mail.
The purpose of the Social Security Number is to track earnings, determine eligibility for Social Security benefits, and monitor individual contributions to the Social Security system.
Information that must be reported includes your name, Social Security Number, age, employment history, and earnings information.
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