Print Form fax cover sheet ONE COVER SHEET PER CLIENT - UPPERCASE ONLY To: Los Angeles County California Children s Services Fax: (855) 481-6821 Number of Pages: Provider Information (Including Cover Sheet) Name: Organization: Phone: - - Return Fax: - - Client Information Last Name: First Name: CCS : Gender: Date of Birth: (MM/DD/YYYY) - - Comments: Confidentiality Notice: This fax is intended for the exclusive use of the recipient named above..
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