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Get SC DPH CC4C 2011-2024

Child’s Name: Referral Date (mm/dd/yyyy): Date of Birth (mm/dd/yyyy): Gender: Female Male Race: Asian American Indian or Alaska Native Native Hawaiian or Other Pacific Islander Caucasian or White Black or African American Medicaid ID #: Uninsured Health Choice Private Insurance Applied for Medicaid? Yes No Name Private Ins. Company: Parent or Guardian Information Parent/Guardian’s Name: Date of Birth (mm/dd/yyyy): Primary Language Spoken in Home: Needs Interpreter? Yes No Street Address: P.O.

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