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A Health Care Provider may charge reasonable clerical costs incurred in locating and making the records available for inspection CA Health Safety Code 123110 a 2008. Records Request To Fax Phone I hereby request that my medical records be release to ROYO EYE CARE Eye Physician Comprehensive Optometrist Adam T. Shupe O. D. 320 H Street Marysville CA 95901 530 743-1873 530 743-1460 FAX Patient Name Patient Date of Birth Patient Signature Date CONFIDENTIALITY NOTICE This message and any...
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