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Get 7385 Cdcr 2019-2024

Ctions must be completed for the authorization to be honored. Use "N/A" if not applicable. I. Patient Information Last Name: Middle Name: First Name: CDCR# Date of Birth: Street Address: City/State/Zip: II. Individual/Organization Authorized to Release Personal Health Records if Other Than CDCR Name: Address: City/State/Zip: III. Individual/Organization to Receive the Information [45 C.F.R. § 164.508(c)(1)(ii), (iii) & Civ. Code § 56.11(e), (f)] The undersigned hereby authorizes CDC.

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