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Get WA DSHS 17-063 2016

IDENTIFICATION NUMBER DATES OF SERVICE LOCATION OF SERVICE DISCLOSE TO: NAME LAST FIRST MIDDLE TITLE ORGANIZATION OR BUSINESS NAME IF APPLICABLE ADDRESS CITY TELEPHONE NUMBER (INCLUDE AREA CODE) FAX NUMBER (INCLUDE AREA CODE) STATE ZIP CODE E-MAIL ADDRESS REASON FOR DISCLOSURE (NOT REQUIRED) AUTHORIZATION: SOURCES: I authorize the following DSHS programs to disclose or give access to confidential information about me as described below. Information may be provided verbally or b.

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