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) FROM: (Nursing Facility/Waiver Agency) (Provider Number) DATE: SUBJECT: (Recipient Name) (Social Security Number) (Previous Address) (City) (State) (ZIP) (Responsible Relatives Name) (Street Address) (City) (State) (ZIP) This is to notify you that the above referenced recipient: was admitted to this nursing facility/waiver agency on is in Title (Date) (XVIII or XIX) Placement Status, and was placed in a: Nursing Facility Bed ICF/ /DD Bed Mental Hospital Bed EPSDT Bed Home and Co.

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