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Get CA HHSA LIC 625 2012-2021

UTHORIZED REPRESENTATIVE(S)/FACILITY SOCIAL WORKER/PHYSICIAN/OTHER APPROPRIATE CONSULTANT SIGNATURE DATE I/We have participated in and agree to release this assessment to the licensee(s) with the condition that it will be held confidential. CLIENT’S/RESIDENT’S OR CLIENT’S/RESIDENT’S AUTHORIZED REPRESENTATIVE(S) SIGNATURE LIC 625 (6/12) CONFIDENTAIL DATE PAGE 4 OF 4 .

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