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Get TX 3616 2012

Iver Program TxHmL Requested Termination Date Individual (Last Name, First Name) HCS CARE/Client ID Local Case No. Medicaid No. Date of Birth (MM/DD/YYYY) Service Coordinator (SC) (Last Name, First Name) Local Authority (LA) SC Email Address SC Area Code and Telephone No. Ext. Program Provider's Legal Name (Do not use DBA name.) Component Code Vendor No. Consumer Directed Services Agency (CDSA) Legal Name (if applicable) (Do not use DBA name.) Component Code Vendor No. Reason f.

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Keywords relevant to TX 3616

  • IPC
  • Lon
  • yyyy
  • 2012
  • ext
  • verifies
  • ELIGIBILITY
  • applicable
  • SC
  • Certification
  • enrollment
  • terminating
  • enroll
  • LOC
  • medicaid
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