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Get CA MH 617 2004-2024

Clear entire form DEPARTMENT OF MENTAL HEALTH DMH FAX COVER FOR TRANSMITTING PHI FAX DETAILS Date Transmitted Time Transmitted Number of Pages including cover sheet Intended Recipient TO FROM Name Facility Address Telephone Fax Documents being faxed Clinical Records Other CONFIDENTIALITY STATEMENT This facsimile transmission may contain information that is privileged and confidential and is intended only for the use of the person or entity name.

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