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Get Level Of Care Certification For Facility - Iowa Department Of Human ... - Dhs State Ia

Level of Care Certification for Facility PLEASE PRINT OR TYPE Fax form to Iowa Medicaid Enterprise Medical Services 515 725-1349 Medical professional completing this form must provide a copy to the admitting facility. Today s Date / Iowa Medicaid Member Name Social Security or State ID Birth Date Name Telephone Number 10 digits Address City State Zip Admit to Nursing Facility Intermediate Care Facility for the Intellectually Disabled Discussion o.

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