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The following requirements shall use this form: Section III. A., B., or C. of the Med-QUEST Division's Criminal History Record and Background Check Standards. UTILIZATION This form shall be used by individuals working for or seeking employment with organizations that have contracts with the Department for the provision of direct services (or serve in direct contact) to a Medicaid beneficiary. COMPLETION OF THE FORM Complete a separate DHS 1200 form for EACH exemption being requested. F.

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