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Get WV DNR-CR-DDFL1 2018-2024

) APPLICATION As a Physician / APRN / PA licensed by the State of West Virginia, I do hereby certify that the following individual has a developmental disability, pursuant to the criteria specified below: The term Developmentally Disabled as used in W. Va. Code 20-2-28(j) refers to a person with a severe, chronic disability as described below (check all statements that apply to the applicant): (1) He/she has a mental or physical impairment, or a combination of mental and physical impair.

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