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Get MI DHS-4574 2016

Ive will be used to determine if you are eligible for health care coverage. Be sure to sign your name on pages 2 and 4. You can apply for health care coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) office. Your application must be approved or denied within: • 45 days, or • 90 days if disability is a factor in determining your health care coverage eligibility. Use DCH-1426, Application for Health Coverage and Help.

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