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Get Form 142 Louisiana

Print Form BHSF Form 142 Rev. 07/12 Prior Issue Obsolete SSN Louisiana Department of Health and Hospitals Medicaid Program Notice of Medical Certification Date of Birth Medicaid No To Home Address Facility/Provider/Support Coordinator Name Vendor No Facility Address Parish Nursing Facility or Intermediate Care Facility Eligibility must be approved prior to admission to Nursing Facility.

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