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Get Dss 8655 2005

SSN Address Date Case Manager / Telephone Number PART II. (For Applicant, Recipient, Personal Representative or Guardian) I hereby authorize any physician, hospital, or clinic that has treated or examined me to give the County Department of Social Services information about my present or past health. Date Signature of Applicant, Recipient, Personal Representative, or Guardian ALL INFORMATION BELOW IS TO BE COMPLETED BY A PHYSICIAN. PART III.

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