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ADRC COORDINATOR DATE: / / 1. APPLICANT/CLIENT NAME DATE OF BIRTH / / DHS CASE NO. DHS CLIENT NO. 2. TYPE OF REFERRAL: ADRC INITIAL DETERMINATION ADRC REDETERMINATION DATE LAST ADRC COMPLETED: / / 3. REFERRAL SOURCE: DHS: Division / Section / Unit Name of EW Phone No. Fax No. QUEST HEALTH PLAN: Name of Plan 4. Contact Person Phone No. Fax No. DHS 1127, MEDICAL HISTORY AND DISABILITY STATEMENT DHS 1128, DISABILITY REPORT DHS 1147, SUB-ACUTE/LONG TERM.

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