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Get PA HCBS Form PA 1768 2006

ION ˆ This is to verify that the individual listed has been determined to meet the level of care appropriate for Home and Community Based Services through the program indicated below. Assessment Date: Service Begin Date: ˆ This is to verify that the individual listed does NOT meet the level of care appropriate for Home and Community Based Services through the program indicated below. Assessment Date: ˆ ˆ New Applicant Change ˆ Transfer ˆ Termination (Complete additional informa.

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