State of California – Health and Human Services Agency
Department of Health Care Services
County/DSH/FQHC Staff reads and signs below.
I declare under penalty of perjury under the laws of the State of California that the information above is true
and correct.
Date:
Signature of County/DSH/FQHC Staff
Name of County/DSH/FQHC Staff
(print):
First
Middle
Last
Information:
Name of agency
County
Telephone number
E-mail
County fi lls out this box
Case No:
Case Name:
DHCS 0005 (02/08) – Korean
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