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Get DSH-001 2013

IP. Refer all children aged 19 and under to the DCBS office in the county of the individual’s residence for a KCHIP eligibility determination. Section 1: Individual Information 1. 2. 3. 4. Today’s Date: Patient’s Name: Street Address: City: State: Zip Code: 5. *Social Security Number: 6. Date of Birth: 8. 9. Work Phone: 10. Dates Hospital Provided Service: 11. Married/Single: 12. Name of Spouse: 13. Is the patient pregnant? Yes No If YES, refer the patient to DCBS for Medicaid eligibili.

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