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Get Medicaid Home And Community-Based Services: Results From A 50 ...

The following questions for the individual that is to receive Intensive Behavioral Services. You must sign and date the form before submission. Submit the completed application to your liaison at your local DDSO or Region 2 office in New York City. With this completed form you should also submit any other supporting materials (see questions #7 and #8). Date Initial Application Reauthorization Application. Explain (include dates) SECTION I Name of person completing the application Affiliation (.

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