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Get CA HHSA DSS LIC 9020 2011

Enter the name, address, and telephone number of the client/resident attending physician. 9. Responsible Person: Enter the name, address, and telephone number of the person responsible for the client/resident. “Responsible Person” means that individual or individuals, including a relative, health care surrogate decision maker, or placement agency, who assists the resident in placement or assume varying degrees of responsibility for the resident’s well-being. LIC 9020 (8/11) CONFIDENTIAL .

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