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Get and Sign INSTRUCTIONS DHS 1139D 0408 ACUTE HOSPITAL ATTACHMENT PURPOSE Form DHS 1139D Shall Be Used by Health Care Facilities Who Provide 2008-2022

Get and Sign INSTRUCTIONS DHS 1139D 0408 ACUTE HOSPITAL ATTACHMENT PURPOSE Form DHS 1139D Shall Be Used by Health Care Facilities Who Provide 2008-2022

Use a INSTRUCTIONS DHS 1139D 0408 ACUTE HOSPITAL ATTACHMENT PURPOSE Form DHS 1139D Shall Be Used By Health Care Facilities Who Provide 2008 template to make your document workflow more streamlined.

Print Name of Provider Self Explanatory 2. Signature Self Explanatory 3. Date Signed Self Explanatory. INSTRUCTIONS DHS 1139D 04/08 ACUTE HOSPITAL ATTACHMENT PURPOSE Form DHS 1139D shall be used by health care facilities who provide acute inpatient hospital services. This form shall be submitted with a completed DHS 1139 Medicaid Application/Change Request Form* 1. ...
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