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Get ND SFN 600 2017-2024

Nt Identification Number (ND Number) County of Residence State ZIP Code Level of Care (LOC) Screening Effective Date SECTION II. SERVICES (formal) SERVICE PROVIDER PROVIDER NUMBER UNITS PER MONTH UNIT RATE Contingency Plan COST/MONTH Total Cost SECTION III. VINELAND SCORE Communication Daily Living Socialization Motor V-scale Score Total Score SECTION IV. SIGNATURES I am aware that I may have a recipient liability/ service fee. I selected the services listed above. I selected.

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