• AUTHORIZATION FOR RELEASE OF MEDICAL RECORDS

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  • 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

     

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  • 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. 

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