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Get CA DS 1805 2001

Ant) Date of Birth Page 1 of 2 Medicaid Home and Community Based Services Waiver Participant? (Check one) Yes No Address Daytime Telephone No. Name of Regional Center or State Developmental Center: A State level fair hearing will be scheduled. In an effort to resolve this matter prior to a fair hearing, I am also requesting the following: (Check all that apply) G An informal meeting with the regional center’s or state developmental center’s director, or his/her designee. G Mediation .

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