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New Patient Enrollment Form Name (Last)___(First) ___ Date of Birth___Social Security Number___ Address___ City___State___Zip Code___ Phone: Home___Cell___Work___ Email Address___Additional family
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Additional family members refer to individuals related to the primary filer who may also have relevant financial or identification information that needs to be disclosed in certain tax or legal documents.
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Information that must be reported includes the names, Social Security numbers, dates of birth, and relevant financial details of each additional family member.
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