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Get CA LIC 605 A 2000-2024

, HOSPITAL, HOSPICE, HOME HEALTH AGENCY, ATTENDING NURSE, PSYCHOLOGIST, COUNSELOR, THERAPIST, ETC.) (ADDRESS) I hereby authorize you to release any and all medical or confidential information contained in the record of: (NAME OF PERSON) (NAME AND ADDRESS OF FACILITY, PERSON OR AGENCY REQUESTING INFORMATION) THIS AUTHORIZATION SHALL EXPIRE ON: (DATE) (CLIENT OR AUTHORIZED REPRESENTATIVE) (RELATIONSHIP TO PERSON ON WHOM INFORMATION IS REQUESTED) (ADDRESS) NOTE: 1. The person who authorize.

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Keywords relevant to form release client information

  • Hospice
  • revoke
  • conform
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