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Get CA Authorization to Share Protected Personal Information - Contra Costa 2017

E, please contact the Homeless Court Coordinator @ (925) 608-6700 AUTHORIZATION TO SHARE PROTECTED PERSONAL INFORMATION I give authorization for my basic and personal information (including, but not limited to, name, gender, birth date, ethnicity, marital status, household configuration, military status, primary language spoken, and non-confidential services requested and received) to be shared with the organizations with which the Contra Costa Public Health Homeless Program operates and author.

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