34 PM 357 10/2007 Required Form 37. DSS worker telephone services. Contact attempt with responsible person Type of Contact Date Result Who Contacted FINAL RESULT Face-to-face Contact made Telephone Mail Type Client Name T S Assistance Given Provider Name and Telephone Appt.
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How to fill out the 75eo 0m online
This guide provides a step-by-step approach to filling out the 75eo 0m form, designed for Medi-Cal eligible individuals under 21 years of age seeking health and dental check-ups. It aims to assist users in completing the form accurately and efficiently online.
Follow the steps to successfully complete the 75eo 0m form online.
- Press the ‘Get Form’ button to access the form directly and open it in your preferred editor.
- Carefully fill in the unshaded areas of Part A, ensuring you provide all relevant personal information, including case name, county code, aid code, and case number.
- For question 5, indicate whether you are requesting additional information without needing services.
- Answer questions 6 through 11 regarding your requests for medical and dental services, as well as transportation and scheduling needs, by selecting 'Yes' or 'No' as appropriate.
- Complete questions 12 through 19, marking whether this is a new application, redetermination, or other relevant options, and provide your primary language and any special circumstances.
- Input personal identification information for clients, including names, birth dates, and contact information in sections 21 to 32.
- Utilize the comments section to provide any additional notes that will assist in processing your service requests.
- After completing the form, you have the option to save your changes, download a copy, print the completed form, or share it as needed.
Start filling out your 75eo 0m form online today!
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