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Get Medicaid 5045 Form 2019-2024

of social services, attending physician, and Division of Health Benefits (DHB) about the anticipated duration of treatment for an individual under age 21. The information is required for a determination of financial eligibility for Medicaid. SECTION A: REQUEST TO PHYSICIAN (Completed by County DSS) Name of Individual __________________________________ Date of Birth ______________ Medicaid coverage has been requested for medical care and treatment in an institutional setting for the above-named .

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