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Program Registration Caregiver Referring Agency: Referring Staffs Name: Referring Staffs TitleContact Date /Phone: Email: Release of Information signed on:ID Number / Initial/Basic Demographics Last
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The state of CaliforniaHealth is a form used for reporting health insurance coverage.
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Individuals and businesses who provide health insurance coverage are required to file the state of CaliforniaHealth form.
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The purpose of the state of CaliforniaHealth form is to report health insurance coverage to the state government.
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Information such as the names and social security numbers of individuals covered, the type of coverage provided, and the months in which coverage was provided must be reported on the state of CaliforniaHealth form.
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