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Get CA SOC 426A 2016

Lack or blue ink. Print information clearly. • You (or your authorized representative) must complete PART A of this form to let the county know who you have chosen to provide your authorized services. • If you have multiple providers, you must fill out a separate form for each person who will be providing authorized services for you. • You must sign the acknowledgement in PART C of this form. • Please return this completed and signed form to the county. The county will keep the o.

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