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STATE OF NEW YORK OFFICE FOR PEOPLE WITH DEVELOPMENTAL DISABILITIES HCBS Form 02. 02. 97 5/2010 4/2011 Form URAC-2 4-86 ICF/MR-LEVEL OF CARE ELIGIBILITY DETERMINATION LCED FORM Please refer to the accompanying instructions for information on completing this form. Name of Individual Status 620 / 621 D. The LCED is redetermined to be effective for one year i.e. 365 days from the signature date below. Signature and Title of Qualified Person Completi.

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