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Get OR DHS 7494 2014

Mediately. Instructions to provider (please read the provider responsibilities below): • Use black or blue ink and print clearly.    Ź&RQWDFW'LUHFW3D\8QLW '38 IRUTXHVWLRQVDW 1-800-699-9074 (toll free)RU(Salem area). • &RPSOHWHWKLVIRUPZLWKLQGD\VIURPWKHGDWHLVVXHGLQWKH“DHS branch Use Only”VHFWLRQDQGPDLOLWWR                                              '38 32%R[ 6DOHP25.

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