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Fill and Sign the Patient Enrollment Form

Fill and Sign the Patient Enrollment Form

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Open the document and fill out all its fields.
Apply your legally-binding eSignature.
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Review and Verification of Circulation Publication Number Publication Title _ Issue Frequency Issue Verified Authorization Section Type of Advertising Authorized General Pub Only Contact Name and Telephone Number Date None Review Print Order or Press Run (Total copies printed) 1. Total Copies Mailed 2. Other Distribution 3. Remaining Copies Note: Total of items 1, 2, and 3 must equal the print order or press run. Distribution Information (A) Publisher's Count 1. Total Number of Direct Subscriptions (Including gift subscriptions) 2. Total Number of Subscriptions as Part of Dues 3. Total Number of Paid Subscriptions Through Agents 4. Total Number of Direct Requests Including Internet and Telephone (Only for requester publications) 5. Single Copies Sold Over Counter, Coin Machines, Street Vendors With Return Privilege Copies Furnished 6. to News Agents and Dealers (Report returned copies in line 15) Without Return Privilege Total Sold Total Sold 7. Copies Purchased in Bulk Other Than News Agents and Dealers/Bulk Requests (Not invariably paid) 8. Other Requested Copies 9. Advertiser Proof Copies (No more than one copy per advertiser) 10. Exchange Copies 11. Other Paid Circulation (Specify) 12. Total Paid/Requester Circulation (Lines 1 through 11) PS Form 3548, April 2000 Total (1 + 2 + 3) (B) Verified Count (A) Publisher's Count Distribution Information (B) Verified Count 12. Total Paid/Requester Circulation From Side One a. Mail Samples b. Requests Induced by Premium Offer or Other Material Consideration c. Nominal Rate (Except requester publication) Nonsubscriber or 13. Nonrequester Copies d. Carrier Samples e. Expired Subscriptions/Requests f. Other g. Total Nonsubscriber or Nonrequester Copies (Sum of lines 13a through 13f) 14. Total Distribution (Sum of lines 12 and 13) 15. Copies Furnished to News Agents and Not Sold (Returned or destroyed) 16. Office Copies, Spoiled Checking Copies, etc. 17. Total Production (Sum of lines 14, 15, and 16) 18. Percent Paid/Request Circulation (Line 12 divided by line 14) Comments (For publisher's use) I certify that all information furnished on this form is true and complete. I understand that anyone who furnishes false or misleading information on this form or who omits material information requested on the form may be subject to criminal sanctions (including fines and imprisonment) and/or civil sanctions (including multiple damages and civil penalties). Signature of Publisher or Representative Title Date X Comments (For USPS use) Verification Performed By PS Form 3548, April 2000 (Reverse) Telephone Number (Include area code)

Useful assistance on preparing your ‘Patient Enrollment Form’ online

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  2. Click +Create to upload a file from your device, cloud storage, or our form library.
  3. Open your ‘Patient Enrollment Form’ in the editor.
  4. Click Me (Fill Out Now) to prepare the document on your end.
  5. Add and designate fillable fields for others (if necessary).
  6. Continue with the Send Invite settings to request eSignatures from others.
  7. Save, print your copy, or convert it into a reusable template.

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