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Get CA DS 1852 2015-2024

OVAL: Initial Program Plan approval: Conversion from CCF level facility Change of ownership New facility QIDP Approval: Attach copy of degree and resume LICENSE CATEGORY: ICF/DD-H Program Plan NOTIFICATION OF CHANGES: Changes to existing Program Plan Change of address or phone Other: ICF/DD-N Program Plan ICF/DD Program Plan: Annual Approval FACILITY NAME: Telephone: (____) ___________________ *MEDI-CAL PROVIDER ID #05G__________ or #55G ___________ Fax: (____) ___________________ E-ma.

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