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Get WI DHS F-00309 2012

Ng Centers, and American Indian Tribes or Bands Providing Personal Care Services This form is used to collect contact and personal care services information from Wisconsin Medicaid (MA) personal care providers that are Counties, Independent Living Centers, or American Indian Tribes or Bands and that contract, provide, or arrange for personal care services. Questions about completion of this form may be directed to DQA’s Bureau of Health Services at 608-266-2702. RETURN THIS COMPLETED FORM TO:.

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