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Get Time Away From Work Hca

O www.basichealth.hca.wa.gov or call Basic Health at 1-800-660-9840. If you need additional copies of this form, you can print them from the Internet at www.basichealth.hca.wa.gov, call Basic Health to request them, or photocopy this form. Be sure to refer to the letter you received with this form for details on timing and other documentation Basic Health needs from you. SECTION ONE CURRENT SUBSCRIBER Social Security number (SSN) - House number Last name Street address First name Ap.

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