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PATIENT INFORMATION Name: ___ Nickname: ___ DOB: ___ SS#: ___ Address: ___ City: ___ Zip: ___ Home: ___ Cell: ___ Email: ___ Sex:MFMarriedDivorcedSingleMinorPartnered for ___ yearsPatient Employer/School:
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This section refers to the required tax form for reporting income and expenses.
Individuals and businesses who have earned income or incurred expenses are required to file this section.
This section can be filled out electronically or by mail using the provided forms and instructions.
The purpose of this section is to report financial information to the government for tax purposes.
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