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Get Alabama Medicaid Statement Of Claimant Form 234

Date of statement 8. Telephone Number 9. Mailing Address Signature of Witness 1 Address of Witness 1 ALABAMA MEDICAID AGENCY STATEMENT OF CLAIMANT OR OTHER PERSON 1 2 Name of Person Making Statement if other than above claimant Understanding that this statement is for a right to payment of Medicaid benefits by Alabama Medicaid Agency I hereby certify that SIGN ON BACK I understand that anyone who knowingly makes a false statement or misrepresents.

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How to fill out and sign Alabama Medicaid Statement Of Claimant Form 234 online?

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