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Entifying Information 2. Medicaid Number: 1. Applicant s Name/Address: 3. Social Security Number 4. Sex Age 4A. Birthdate ---------------------------------------DFCS County 5. Primary Care Physician Mailing Address 7. Does guardian think the applicant should be institutionalized? Yes No 6. Applicant s Telephone # 8. Does child attend school? Yes No 9. Date of Medicaid Application / / Name of Caregiver #1:.

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