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PATIENT AND EMPLOYEE INFORMATION PATIENT IS FULL NAME: First Middle Last D.O.B. PATIENT IS ADDRESS: City State iPhone Phone: Work Phone: SOCIAL SECURITY NUMBER: Financially Responsible Party:MARITAL
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The OMB No 3220-0039 application is a form used for reporting information to the Office of Management and Budget (OMB).
Certain organizations or individuals may be required to file the OMB No 3220-0039 application based on specific criteria set by the OMB.
The OMB No 3220-0039 application can be filled out online or submitted through mail following the instructions provided on the form.
The purpose of the OMB No 3220-0039 application is to collect data and information for OMB's analysis and decision-making processes.
The OMB No 3220-0039 application may require reporting of specific financial, operational, or demographic information depending on the nature of the organization or individual filing.
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