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Get Communication Form - Dshs - Dshs Wa

BIRTH GENDER HCBS CORE WAIVER CLIENT RESIDES IN THE FOLLOWING SETTING (PLEASE CHECK ONE) Male Yes No ACES CLIENT ID ETHNICITY SOCIAL SECURITY NUMBER Female Foster Home Staffed Residential Group Care Facility DATE ENTERED INTO VOLUNTARY PLACEMENT DATE APPROVED FOR WAIVER Foster Parent s Information LAST NAME TELEPHONE NUMBER (INCLUDE AREA CODE) FIRST NAME RESIDENTIAL ADDRESS STATE CITY ZIP CODE WA MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE WA Staffed Residentia.

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