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All Kids Application Form
All Kids/FamilyCare Application Fax Transmittal Sheet DATE: TIME: FROM: TO: ALL KIDS UNIT 217 785-1647 PHONE #: ALL KIDS Application Agent: Provider ID #: Number of pages: Applicant's Name: (Last) (First) Applicant's Date of Birth: Describe reason for application priority processing: REMINDER: Only Fax new applications. Do NOT mail the original application after faxing. HFS 3710 (R-11-09) Print Form ...Show details
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