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IV ()Fax completed form to: (855) 8401678 If this is an URGENT request, please call (800) 8824462 (800.88.CHINA)PHYSICIAN INFORMATIONPATIENT INFORMATION* Physicians Name: Specialty:*Due to privacy
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The fax completed form is sent to the relevant authority or organization specified by the form instructions.
Individuals or entities specified in the form instructions, such as businesses or taxpayers, are required to file the completed form.
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Information that must be reported includes identification details, financial data, and any other information specified on the form instructions.
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