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  • Take Charge Card Form

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Grandchild Other - - Name (first, middle initial, last) Social Security Number Date of Birth (month, day, year) Relationship to You: Child Step-Child Grandchild Other - - Name (first, middle initial, last) Date of Birth (month, day, year) Social Security Number Relationship to You: Child Step-Child Grandchild Other - - 5. Health Insurance Do you have health insurance? Yes Fill Out Below No Go to Question 6 Policyholder s Name Cov.

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CAREGIVER Related content

Take Charge Plus | Department of Health | State of...
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Authorization for Credit Card Transactions | USCIS
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Related links form

FL DR-191 2012 FL DR-1C 2018 FL DR-1C 2012 FL DR-26 2019

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If you are not sure if you have Medicaid health coverage, call Medicaid Customer Service toll free at 1-888-342-6207.

If you are not sure if you have Medicaid health coverage, call Medicaid Customer Service toll free at 1-888-342-6207.

Take Charge Plus provides health coverage for family planning and family planning related services. What does Take Charge Plus Cover? (Services, prescriptions and supplies must be related to family planning.)

What is Take Charge Plus? Take Charge Plus is health coverage for family planning services, medicines, supplies, transportation, and more. Click here to see more information about Take Charge Plus.

Take Charge Plus provides health coverage for family planning and family planning related services. What does Take Charge Plus Cover? (Services, prescriptions and supplies must be related to family planning.)

You can contact Medicaid by phone at 1-888-342-6207 or by email at MyMedicaid@la.gov. You can get help in person at a Medicaid Application Center or Medicaid Office. You can also download and print a Medicaid application and then mail or fax it to Medicaid as directed on the form.

COVERED SERVICES: Birth control (pills, implants, injections, condoms, and IUDs) Cervical cancer screening and treatment for most abnormal results. Contraceptive counseling and education.

LaCHIP provides Medicaid coverage for primary care doctor visits as well as preventive and emergency care, immunizations, prescription medications, hospitalization, home health care and other health services.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
All Forms
Search all Forms
Industries
Forms in Spanish
Localized Forms
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232