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Get Interagency Notification Of Termination Of Medicaid Waiver Eligbility For A Community Waiver

MEDICAID WAIVER ELIGIBILITY FOR A COMMUNITY WAIVER PARTICIPANT This form is to be filled out by the Income Maintenance worker and sent to the Care Manager/Support and Services Coordinator when the Medicaid Waiver participant loses Medicaid Waiver eligibility. Name - Community Waiver Care Manager / Support and Services Coordinator Name Income Maintenance Worker Name - Waiver Participant Case Number Social Security Number Medicaid Waiver Termination Date Reason for Termination Addition.

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