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3244p Dhs 2016-2023
MEDICARE NUMBER
Yes
ZIP CODE
WHICH PCA SERVICE MODEL DOES THE RECIPIENT CURRENTLY USE?
Traditional PCA
PREPAID HEALTH PLAN
PHONE NUMBER
Female
CITY
PRIMARY CONTACT OR RESPONSIBLE PARTY
PMI NUMBER
PCA Choice
MAJOR PROGRAM (See Pg. 2 for definitions)
No THIRD PARTY LIABILITY (INSURANCE) NAME
IM
KK
LL
MA
NM
RM
EH
BB01
Yes
No WAIVER/AC
Yes
Physician information
PHYSICIAN NAME
PHYSICIAN CLINIC
ADDRESS
PHONE NUMBER
CITY
STATE
ZIP CODE
PCA provider(s)...
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