Get CA Kaiser NS-9934 2015-2021
Whether you sign this authorization. This disclosure is made at your request. For Virginia patients, a copy of this authorization, and a note stating to whom your information was disclosed will be included in your medical record. A copy of the original authorization is valid. You have a right to a copy of this completed authorization. Date Signature NS-9934 (9-15) SPANISH-NS-1614; CHINESE-NS-6274 NCAL: 90258 (REV. 9-15) SPANISH 01782-000; CHINESE 01782-002 If personal representative, print na.
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