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Get DHS 1139F Instructions 2013-2024

Facility For The Developmentally Disabled/Intellectually Disabled Individuals (ICF-DD/ID) Attachment form shall be used by health care facilities who provide intermediate care facility services for the developmentally disabled or the intellectually disabled individuals. This form shall be submitted with a completed DHS 1139, Medicaid Application/Change Request Form. INSTRUCTIONS: 1. Print Name of Provider/Authorized Business Agent Self-explanatory. 2. Name of Health Care Facility Self-explan.

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Keywords relevant to DHS 1139F Instructions

  • medicaid
  • intellectually
  • attachment
  • provider
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