to release health information to LOS ANGELES PRIMARY CARE
1711 W. TEMPLE ST ste 4691, LOS ANGELES, CA 90026
TEL: 213-238-5887 FAX:213-444-7212
I understand that the release of transfer of the information specified above to any person or entity not specified above is prohibited.
I understand that I may revoke this consent at any time except to the extent that action has already been taken and that it will expire twelve months from the date indicated below.