Get IA 470-2917 2019
If available. 13 Email Address – Enter email address, if available. By providing your email address, you agree that we may communicate with you by electronic mail. 14 Desired Effective Date for Enrollment – This date cannot be retroactive before the first of the month in which the application is approved. Providers cannot bill or be paid for service provided prior to the Department of Human Services (DHS) approval of the service enrollment. 15 County of Service – Circle all counties .
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