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Little Company of Mary San Pedro Hospital CA 90732 310 Form
Making further disclosure of my health information unless the Requestor obtains another authorization from me or unless such disclosure is specifically required or permitted by law. This authorization expires on or in six months if not specified. Neither treatment payment enrollment or eligibility for benefits will be conditioned on my providing or refusing to provide this authorization. Name of Requestor Date Patient Signature or Responsible Party X Telephone Number of Requestor Relationship...
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