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MEDICAID/SLH/FAMIS APPEAL REQUEST FORM First Name of Medicaid/SLH/FAMIS Applicant/Recipient Middle Name Last Name City and State Zip Code 9-Digit Contact Telephone Medicaid/SLH/FAMIS Case Social Security Other Telephone Street or Post Office Box I am appealing the action of agency name I am a community spouse appealing the income/resource maintenance standard. 032-03-851/ 1 10/02 INSTRUCTIONS Complete this form as fully as possible or write a le.

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