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Forms You Might Need DSHS 2018
DSHS may still share information about you to the extent allowed by law. If you have questions
about how DSHS shares client confidential information or your privacy rights, please consult the DSHS Notice of Privacy Practices or ask the person
giving you this form.
CLIENT IDENTIFICATION:
NAME
DATE OF BIRTH
ADDRESS
IDENTIFICATION NUMBER
CITY
TELEPHONE NUMBER (INCLUDE AREA CODE)
STATE
ZIP CODE
OTHER INFORMATION
CONSENT:
I consent to the use of confidential information about me within...
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