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Get Demographic Form For Interim Icf/mr Level Of Care - Alaska ...

E Start Date: Date Demographic Form Submitted: 1) At the time of the last ICAP, was the client living in, or within 3 months of discharge from, an institution, Yes No correctional facility, or long-term care facility? Name of Facility: Discharge Date: 2) Primary Diagnosis: Secondary Diagnosis: 3) Have there been significant changes in the client s behavior or health in the last year? Specify and attach appropriate supporting documentation: Yes No Letter attached from a qualified profess.

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