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Get 310 423 0113 2015-2024

Unless otherwise specified: Signature: Date: (Patient, Power of Attorney for Healthcare or Legal Representative) Legal Representative Relationship: Health Information Management Department 8700 Beverly Blvd., Room 2901, Los Angeles, CA 90048 Email: GroupHIDInternetInquiries cshs.org Phone 310-423-2259 Fax: 310-423-0113 Form No. 2034 (Rev. 6/5/15) Back.

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