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Get MA Enrollment Assessment Section 35 2014

Tial: / yyyy Provider ID: Last Name: Suffix: 3. Intake/Clinician Initials: 1. Client Code: 3. Do you own or rent a house, apartment, or room? 3a. Are you Chronically Homeless? (HUD Definition in Manual) Yes No If the answer to Q. 3 is Yes, skip to Q. 3b, if ‘No” answer Q 3a. 3b. ZIP Code of Last Permanent Address: Yes No Do Not put zip code of Program. See Manual for definition of Permanent. 3c. Where did you stay last night?  Emergency shelter 2 Transit.

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