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Get PA PW 123 2006-2024

For the MEDICAID Waiver for Infants, Toddlers and Families. Individual s Name: Parent/Legal Guardian: Current Address: Date Of Birth: I. Social Security Number: Access Number: QUALIFIED PROFESSIONAL CERTIFICATION (Complete Section A if the individual meets ICF/MR/ORC level of care criteria required for waiver funded IFSP services, or Section B if the individual does not). I hereby certify that this individual: has completed all screenings, evaluations and/or assessments necessary to de.

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