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Authorization for Disclosure of Medical Record Information Santa Cruz Community Health Centers P.O. Box 542 Santa Cruz, CA 95060Fax: 8314572486REV 7/17Patient Information Patient Full Name: Date of
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Obtain a copy of the Santa Cruz Community Health form.
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Begin by entering your personal information in the designated fields. This includes your full name, date of birth, address, and contact details.
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Fill out the sections regarding your medical history, including any existing conditions, allergies, and medications you are currently taking.
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Provide information about your insurance coverage, if applicable. This includes the name of the insurance company and your policy number.
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Santa Cruz Community Health is a non-profit organization that provides healthcare services to the community of Santa Cruz.
Santa Cruz Community Health is responsible for filing their own reports and documents.
To fill out Santa Cruz Community Health forms, you can visit their website or contact their office for assistance.
The purpose of Santa Cruz Community Health is to provide accessible and affordable healthcare services to the Santa Cruz community.
The information reported on Santa Cruz Community Health includes patient demographics, medical history, and treatment provided.
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