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FOR THE DEVELOPMENTALLY DISABLED HABILITATIVE/NURSING HOME OFFICE COST REPORT Home Office Name: Reporting Period: From DHS 3099 (12/04) Schedules To State of California Health and Human Services Agency Department of Health Services SCHEDULE 1 HOME OFFICE COST REPORT GENERAL INFORMATION 1. Home Office Name 3. Phone Number 2. Street Address City 4. Cost.

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