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LICENSE NUMBER II. RESIDENT/PATIENT INFORMATION To be completed by the resident/resident s responsible person 2. BIRTH DATE 3. AGE 1. NAME III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION To be completed by resident/resident s legal representative I hereby authorize release of medical information in this report to the facility named above. 1. SIGNATURE OF RESIDENT AND/OR RESIDENT S LEGAL REPRESENTATIVE 3. DATE IV. PATIENT S DIAGNOSIS To be completed by the physician NOTE TO PHYSICIAN The...Show details
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