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THERAPIST OWNED & OPERATEDPATIENT INFORMATION Patients Legal Name ___ Social Security # ___ Sex Birth Date ___ Age ___Marital Status: MarriedSingleWidowedDivorcedMFSeparatedMailing Address ___ City
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This document is used to report shared practice information for Cornerstone Health and Family.
All healthcare providers affiliated with Cornerstone Health and Family are required to file this document.
The document can be filled out online through the designated portal provided by Cornerstone Health and Family.
The purpose of this document is to ensure that shared practice information is accurately reported and documented for Cornerstone Health and Family.
The document requires healthcare providers to report details of shared practices, collaborations, and outcomes within Cornerstone Health and Family.
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