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Get Hfs 243c Form

): I would like to request medical benefits for the person(s) named below Person # 1 Person # 2 Name (Last, First) Sex Male Female Male Female Yes No Yes No Birth date (Month / Day / Year) Social Security Number (or attach proof that you applied for one) Relationship to person completing this form Is this person an Alaska Native or American Indian? If this person is under 19, enter: a. Mother's full name b. Father's full name Has this person received any medical care in the past 3 m.

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