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Get Ucla Medical Release Form

Avenue, CHS BH265, Los Angeles, CA 90095-7305. The revocation will take effect when UCLA Healthcare receives it, except to the extent that UCLA Healthcare or others have already relied on it. I am entitled to receive a copy of this Authorization. EXPIRATION OF AUTHORIZATION Unless otherwise revoked, this Authorization expires (insert applicable date or event). If no date is indicated, this Authorization will expire 12 months after the date of signing this form. SIGNATURE.

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