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Signed by Patient Date Or Signed by Personal Representative On Behalf of DHCS 6247 11/07 Page 1 of 2 IDENTIFYING INFORMATION COPY OF IDENTIFICATION ATTACHED TYPE CA DRIVER S LICENSE CA DMV IDENTIFICATION CARD BIRTH CERTIFICATE BENEFITS IDENTIFICATION CARD MANAGED CARE CARD STATE OR FEDERAL EMPLOYEE ID CARD NUMBER IF NO IDENTIFICATION IS ATTACHED YOUR SIGNATURE MUST BE NOTARIZED.

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