AUTHORIZATION TO PROVIDE MEDICAID WAIVER SERVICESClear FieldsNORTH DAKOTA DEPARTMENT OF HUMAN SERVICES AGING SERVICESHOME AND COMMUNITY BASED SERVICES SFN 410 (82017)By accepting this Authorization.

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  4. Proceed to section two, which may require you to provide relevant identification numbers or licenses, depending on the context of the form.
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  6. Once all sections are completed, review your entries carefully to confirm all information is correct.
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