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Get APPLICATION FOR MR/DD SERVICE REGISTRY - Chfs Ky

Ave any information blank in section 1. Applications will be returned if left blank. Name - Legibly print first, middle and last name of applicant Sex - Check whether the applicant is male or female SS# - Be sure the social security number has 9 numbers Medical Assistance Number - This is the # on the MEDICAID card (10 numbers) DOB - example: 08/18/1966 Phone Number - Always include area code. If no phone, please write no phone Current Address - Please print legibly. Name: Sex: First Soc.

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