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Denied/Withdrawn due to. Presumptive eligibility is authorized from through. DATE DMA-5033 10/13 INCOME MAINTENANCE CASEWORKER Information You Should Take With You to Social Services 1. Instructions for Completion of Presumptive Eligibility Transmittal Form 1. Complete 4 copies original and 1 copy County DSS cc Provider cc Patient 2. PRESUMPTIVE ELIGIBILITY TRANSMITTAL FORM SECTION I TO BE COMPLETED BY PROVIDER PROVIDER NAME AND NPI NUMBER PATIE.

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