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Get IA DHS 470-2577 2007-2024

S a medical facility and the stay is expected to last 30 days or more. This resource information is then used to determine if the spouse in the facility can qualify for Medicaid. HOWEVER, THIS FORM IS NOT AN APPLICATION FOR MEDICAID. Identifying Information: Name of spouse in medical facility Social security number Facility name Birthdate Telephone ( ) Street City State Zip code Date of first entry into the facility (including entry into a hospital immediately before entering the facili.

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