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Get CA SOC 873 2011

ON (To be completed by the county) Applicant/Recipient Name: Date of Birth: Address: IHSS Case #: County of Residence: IHSS Worker Name: IHSS Worker Phone #: IHSS Worker Fax #: B. AUTHORIZATION TO RELEASE HEALTH CARE INFORMATION (To be completed by the applicant/recipient) I, __________________________________________, authorize the release of health care information (PRINT NAME) related to my physical and/or mental condition to the In-Home Supportive Services program as it pertains to my .

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