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Get WA DSHS 09-966 2003-2024

Cating records: CLIENT IDENTIFICATION NUMBER MIDDLE DATE OF BIRTH FORMER NAMES OTHER IDENTIFICATION NUMBER DATES OF SERVICE LOCATION OF SERVICE DISCLOSE TO: NAME LAST FIRST MIDDLE TITLE ORGANIZATION OR BUSINESS NAME IF APPLICABLE ADDRESS TELEPHONE NUMBER (INCLUDE AREA CODE) CITY FAX NUMBER (INCLUDE AREA CODE) STATE ZIP CODE E-MAIL ADDRESS REASON FOR DISCLOSURE AUTHORIZATION: I authorize Children’s Administration to release information from my records. I understand that in.

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