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Get Hcra Form 2020-2024

CANT We would like you to fill out as much of Part 1 and Part 2on the front as you can. If you cannot fill it out, a hospital worker will help you. In Part 1, list your name first and then list the names of all relatives that live with you. DO NOT write in Parts 4, 5, and 6. These are for office use only. DO NOT write on the back of this form. In order for this form to count as an application for assistance in paying your hospital bill, you must read, sign and date Part 3 on the front. Be sure t.

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