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Do not write in this box Medical Record #:4000 Cambridge Street Kansas City, Kansas 66160DT4068 Request for RecordsAccount #: AUTHORIZATION FOR THE RELEASE OF CONFIDENTIAL INFORMATION All sections

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All sections of this form include information regarding income, deductions, credits, and other relevant tax information.

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The purpose of all sections of this form is to accurately report taxable income and calculate the amount of tax owed.

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