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ICFID 2018-2022: get and sign the form in seconds

ICFID 2018-2022: get and sign the form in seconds

Use a dma 6 2018 template to make your document workflow more streamlined.

1 8. Does child attend school 9. Date of Medicaid Application / I hereby authorize the physician facility or other health care provider named herein to disclose protected health information and release the medical records of the applicant/beneficiary to the Department of Community Health and the Department of Human Resources as may be requested by those agencies for the purpose of Medicaid eligibility determination* This authorization expires twelve 12 months from the date signed or when...
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  3. Use the Cross or Check marks in the top toolbar to select your answers in the list boxes.
  4. Utilize the Circle icon for other Yes/No questions.
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  6. Insert the current Date with the corresponding icon.
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