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Get SC DHHS Form 1718 2002-2024

Intake Worker: 4. Children Services 5. SC Choice 6. HASCI Waiver 20. Pre-Admission Screening 21. Non-Medicaid PASARR 22. Nursing Home Conversion 23. HMO/Nursing Home 40. TEFRA 41. OSS RCF 99. Other/Unknown CLIENT INFORMATION Name: Permanent Address: City: State: Zip: County: Rural/Urban: State: Zip: County: Rural/Urban: Mailing Address: City: Phone 1: Phone 2: Phone 3: Location: Location: Location: Functional Touch Tone Phone: Toll Free Access: Date of Birth: Social Sec.

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