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INSTRUCTIONS DHS 1139E Rev Med Quest 2008-2023
INSTRUCTIONS
DHS 1139E (Rev. 08/10)
NURSING FACILITY ATTACHMENT
PURPOSE:
Form DHS 1139E shall be used by health care facilities who provide nursing facility
services. This form shall be submitted with a completed DHS 1139, Medicaid
Application/Change Request Form.
INSTRUCTIONS:
1. Print Name of Provider:
Self-explanatory
2. Signature:
Self-explanatory
3. Date Signed:
Self-explanatory
...
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