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Get EPSDT-PCS 90 2019-2024

Ph# ( D Male ) D Female 2. Responsible Party/Curator: Relationship: Address: Home Phone # ( DOB: ) Work or Cell Phone # ( ) By signing this form I give my consent for my medical information to be released to the Department of Health and Hospitals to be used in determining eligibility for Personal Care Services. Signature: Date: II. MEDICAL INFORMATION NOTE: The following information is to be completed by the applicant s attending practitioner. 1. Patient Name: 2. Primary Diagnosi.

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