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Get HHS FOH-6 2013-2024

Ent Patient signature Date signed Signature of Parent/Guardian/Power of Attorney (if patient lacks capacity to sign) Date signed Relationship to patient If insured by Kaiser Permanente, provide your Kaiser Permanente number Patients date of birth (mm-dd-yyyy) This authorization expires one year from the date the patient signed this form in Section 5. This authorization is subject to revocation by the employee at any time except to the extent that FOH has already taken action in reliance o.

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