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Get OK 04MP033E 2018

Home-Based Services (CHBS) worker, as applicable, completes this form to refer a client who is in need of substance abuse assessment, treatments services, or both. Complete one form for each client in the same case. This referral will not be processed without the KK number. Identifying Information Case name County Family's street address AL State City KK number ZIP code Area code Phone number Client Referred for Services First name, MI, last Date of birth Gender Race Eligibility Clie.

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