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State Disability Review Unit Fill Out and Sign Printable PDF Form
COMPLETED BY THE STATE DISABILITY REVIEW UNIT NAME Case Number First Client ID Number CIN Middle Disability ID Number DIN Last Medicaid application date Social Security Number last 4 digits Medicaid Waiver Date of Birth Waiver type Yes No Telephone No Have you ever applied to the Social Security Administration SSA for disability bene ts If Yes when month/year SSA decision date month/year What was the decision If denied for bene ts what was the reason medical or non-medical Did you appeal the...Show details
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