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Get Wegner CPAs FW Consulting DHFS Consumer/Provider Checklist Employer Packet

VICE COORDINATOR NAME: START DATE OF SERVICES: Would the Employer like to be notified of potential Providers in their area? YES Signatures should be made by hand. Use digital signatures only if you cannot print and/or scan these forms. Documents which require signatures will only be accepted if signed. ATTACH REQUIRED INFORMATION EMPLOYER (CONSUMER) Form 2678 Employer/Payee Appointment of Agent Form.

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