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Get Ny Ohip-0031 2010-2024

To: CLIENT IDENTIFICATION NO. REPRESENTATIVE NAME, ADDRESS, AND SOCIAL SECURITY NO. (if applicable) NAME AND ADDRESS OF SERVICE PROVIDER MEDICAID PROVIDER ID# DESCRIPTION OF SERVICE PROVIDED (For Prescription Drugs, Show Name, Strength and Quantity) DATE OF SERVICE (MO/DAY/YR) TOTAL BILL AMOUNT PAID INSURANCE PAYMENT (After Insurance Payment and Spenddown, if any) I certify that the above-named recipient is eligible for reimbursement of paid medical expenses and/or the above-named FHPlu.

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