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HEALTH CARE COORDINATION FORM
Authorization for Disclosure of Health Information hereby authorize:Dale Seaman, pH. D250 W. First Street, 242,Claremont, CA 91711To Coordinate Care with any of the following:Primary Care PhysicianAddressTelephoneFaxPsychiatristAddressTelephoneFaxPsychologist/TherapistAddressTelephoneFax(909) 6219023The
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