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Get Family Planning Form Pdf

E Location Page 2 of 3 DHHS Form 400 (January 2011) NO NO Rights and Responsibilities 1. I know that my children under age 19 who are eligible for Healthy Connections Medicaid can have free health checkups under a special prevention program called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). 2. I know that the information I have given is confidential. I understand that, except as specified below, information including medical information can be released only for purposes.

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