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PURPOSE of THIS FORM This Form Asks You to DPSS

PURPOSE of THIS FORM This Form Asks You to DPSS

Use a dpss monthly earnings report form template to make your document workflow more streamlined.

Form It will not affect treatment by your health care provider. It may impact if you are eligible for DPSS benefits. I understand and agree that my health care provider may provide information about my health to DPSS. DPSS will use this information to determine my eligibility for benefits. If you decide not to sign this form This will not affect your healthcare treatment. This may affect your DPSS benefits. DPSS will use this information to determine your benefits. If you complete and sign this...
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