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<br />CalOptima Health PHA MOU Page 18 of 18 <br /> <br />Other Adult or Legal Representative (Print Full Legal Name) <br /> <br />Signature Date <br /> <br /> <br />Email Address Date of Birth Telephone number <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />EXHIBIT 1