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S admission into the ICF and request a nursing assessment by the long-term care (LTC) nurse. Resident information: Last name M.I. First Client identification (ID) number Social Security number Date of birth Case number Gender Male Primary language Female Is the resident able to participate in the assessment process? Yes No Facility information: Date of ICF admission Date of discharge Private pay requesting Medicaid? Yes No Facility name Effective date Phone Address Facility num.

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