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Get Medicaid Waiver 2019-2024

G, MI 48909 Telephone Number: 800-648-3397 Fax: 517-763-0146 SECTION 1: TO BE COMPLETED BY THE PERSON REQUESTING A HEARING Client Name Client Telephone No. Client Social Security No. Client Address (No. and Street, Apt. No.) City State Medicaid ID No. Zip Code Client or Legal Guardian Signature Date What agency took the action or made the decision that you are appealing? Make sure to Client MDHHS attach a copy of the letter from the agency that told the client about their decision. Case No.

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