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Get Non Emergency Medical Transportation Wv

Ink and turned in to the local DHHR office within 60 days of the earliest trip. Name: Date(s) of Travel: Street, Route or PO Box Number: City Zip Code Telephone Number County Social Security Number MA ID number from each patient s Medicaid card (this is the 11-digit number to the left of the person s name on the card): Section II: APPLICANT RESPONSIBILITIES AND SIGNATURE Please read each statement carefully and check either Yes or No. 1. Yes No I understand that I may request a.

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