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SEC. NO. SITE CODE DATE SENT TO DES PROVIDER ADDRESS (No., Street, City, State, ZIP) ELIGIBILITY FACTORS For each applicable item, list the document used to verify. A. Residence PHONE NO. (Include Area Code) B. Identity C. Citizenship FAX NO. (Include Area Code) D. Alien Status (when applicable) DATE OF PATIENT S NEXT MEDICAL APPOINTMENT E. Social Security Number The eligibility factors listed below must be verified for the 30 days prior to the date of application. PROVIDER SIGNATURE.

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