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8901 Activity Road, San Diego, CA 92126Tel. (844) 6274763 Fax: (760) 6357801 499 N. El Camino Real Ste C200 Tendinitis, CA 92024 Tel. (760) 6357800Patient:DOB:ID#Fax: (760) 6357801Date:What problem
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This form is a document used to report lifestyle healthcare information for the specified location in California.
Healthcare providers and facilities are required to file this form.
The form can be filled out electronically or manually, following the instructions provided by the California health department.
The purpose of this form is to collect and track lifestyle healthcare data for the specified location.
Healthcare providers need to report lifestyle healthcare information such as treatments provided, patient demographics, and outcomes.
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