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Inpatient ZIP Code / Patient Address
The address shall include the address number and street name, city, state, and ZIP Code. Do not report the address of the hospital. If more than one address is
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ADULT - PATIENT REGISTRATION
Due to updated Federal guidelines, we are required to obtain specific patient information. Please make sure you answer questions 1-6. Thank you. (1) Patients
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Date (Patient name) (Address) (City, State, Zip Code) Re
This letter is to inform you that I will be discontinuing my professional relationship with you because of (insert reason). For this reason, we will no
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