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Ent’s name (last, first, MI). Gender: Check the patient’s gender. Date of Birth: Enter the member’s date of birth: mm/dd/yyyy. Medicare Coverage: Check whether the patient has Medicare coverage and is receiving Medicare Home Health Benefits. 6. Currently At: Check where the patient is currently located and enter the mailing address. 7. Expanded Early & Periodic Screening Diagnosis & Treatment (EPSDT): Check whether the patient has received expanded early and periodic screening diagnosis &.

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