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Tential beneficiary). It must be completed for potentially eligible Medicaid beneficiaries of all ages. The facility must retain THE ORIGINAL of the Facility Admission Notice in the beneficiary's file. A copy MUST be sent to the Local DHS Office. A copy of the MSA-2565-C will be returned to the facility, noting the eligibility status and patient pay amount of the resident. Authority: Completion: Penalty: P.A. 280 of 1939 and Federal 42 CFR of 435 Title XIX of the Social Security Ac.

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