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AUTHORIZATION FOR RELEASE OF INFORMATIONPatient's Name: (please print) Address:City, State, Zip: Last 4 of SSN:Date of Birth:Phone:Email Address: I AUTHORIZE: Dr.TO RELEASE TO or REQUEST From: (940)7668663Name:
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2 information to be refers to a type of report that contains specific details or data that need to be submitted to the relevant authorities.
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The information that must be reported on 2 information to be usually includes financial data, personal details, transaction information, or any other relevant details as required by the authorities.
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