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MLK Community Medical GroupPatient Name:___ Date of Birth:___PATIENT HISTORY FORM ADULT Date of Service:___Date of Birth: ___Name:___Alias / Nicknames:___Main reason for visit:___ MEDICAL HISTORY
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Who needs alias nicknames?
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People who go by different names in different social circles.
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What is alias nicknames?
Alias nicknames are alternative names or pseudonyms that a person may use in addition to their legal name.
Who is required to file alias nicknames?
Any individual or entity who uses alias nicknames in addition to their legal name is required to file alias nicknames.
How to fill out alias nicknames?
Alias nicknames can be filled out by submitting a form or document that lists all alias nicknames being used.
What is the purpose of alias nicknames?
The purpose of alias nicknames is to provide transparency and ensure that all names associated with an individual or entity are known.
What information must be reported on alias nicknames?
The information that must be reported on alias nicknames includes the alias nickname itself and the legal name of the individual or entity.
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