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Get ND DHS SFN 1812 2020-2024

Equires that a physician certify the need for services in an intermediate care facility for each eligible recipient of Medical Assistance upon admission and at least every 365 days (may not exceed 365 days). This is to certify that the recipient named below requires, on an inpatient basis, ICF/IID level of care. 1. Complete the provider, recipient and certifying physician sections of the form. 2. Give this form to the certifying physician to sign. 3. Maintain the original signed copy in your age.

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