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SOUTHERN CALIFORNIA CENTER FOR PAIN MANAGEMENT (English) SC CPM #2 (rev 10/2011) Date (Tech) Patient Authorization/Health Insurance Portability and Accountability Act (HIPPO) 1. Please print the telephone

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1. Start by obtaining the Souformrn California Center for form. You can either download it from the official website or visit a local center to get a physical copy.
2. Carefully read through the instructions provided with the form. This will provide you with important information on how to correctly fill out the form and what supporting documents may be required.
3. Begin filling out the form by providing your personal information in the designated sections. This typically includes your full name, address, contact information, and social security number.
4. If applicable, indicate your marital status and provide the necessary information about your spouse or domestic partner.
5. Move on to the section that pertains to your employment. This may involve providing details about your current job, such as your job title, employer's name and address, and the duration of your employment.
6. Fill out the sections related to your income and finances. This may require you to provide details about your sources of income, such as wages, self-employment earnings, rental income, or any government assistance you receive.
7. If you have dependents, make sure to include their information in the appropriate sections. This will typically include their names, dates of birth, and relationship to you.
8. Review the completed form to ensure all the information is accurate and complete. Double-check for any errors or missing information that may delay the processing of your application.
9. Sign and date the form in the designated space to certify the accuracy of the provided information. If applicable, have your spouse or domestic partner also sign the form.

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1. Individuals who are in need of financial assistance or benefits provided by the California state government.
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For pdfFiller’s FAQs

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The Southern California center is for providing resources and support to individuals in the Southern California region.

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