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Get Medicaid Form 2015 2014-2024

Ephone: Address: Please justify the mode of transportation by entering specific diagnosis and condition affecting the Enrollees ability to use Mass Transit 1. Please check the medically necessary mode of transportation only if the enrollee is unable to use the bus or subway: Livery: The Enrollee can walk to the curb and board and exit the vehicle unassisted, but cannot utilize the bus or subway. Collapsible W/C enrollees who can approach the vehicle and transfer without assistance. Ambulette A.

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