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17I-2 rev10/02 1625 North Market Blvd. Suite N-219 Sacramento CA 95834 www. pharmacy. ca.gov AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION Complainant/Patient Date of birth Person or entity and telephone number from which information may be obtained to disclose all records and information and answer any questions pertaining to the diagnosis and course of my treatment to the Board of Pharmacy Board and its representatives including but not limited to investigators and legal staff upon their...
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