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R ICF/MR APPLICATION AND SERVICE DELIVERY PREFERENCE FORM I. CONFIRMATION OF UNDERSTANDING I, , have been informed of the following: (NAME OF INDIVIDUAL) a. That I am likely to require the level of care provided in an Intermediate Care Facility for people with Mental Retardation (ICF/MR). I understand that this is based on a preliminary determination of eligibility for ICF/MR level of care, and that the determination will.

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