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Date of Birth: Relation to Patient: Relation to Patient: Subscriber #: Subscriber #: Group #: Plan Type: Group #: Copay: Copay: Ins. Street Address: Ins. Street Address: City/St/Zip: Plan Type: City/St/Zip: OV Notes: Pt Balance: The information below will be used to improve the quality of healthcare by granting us the ability to measure and minimize care disparities based on race, ethnicity, and preferred language. It gives our practice an accurate estimate of our patient populati.

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