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Step 1: On the following page, press the orange "Get form now" button.
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The next areas are what you will need to prepare to receive the prepared PDF file.
Fill out the No Street, AptUnit Number, City, StateProvince, Country, ZIP CodePostal Code, SECTION IV GENERAL INFORMATION To, NOTE Your states Medicaid program, DATE ADMITTED TO NURSING HOME, IS THE NURSING HOME A MEDICAID, YES, HAS THE PATIENT APPLIED FOR, A IS THE PATIENT COVERED BY, B DATE MEDICAID PLAN BEGAN MMDDYYYY, and YES fields with any data that are asked by the software.
The program will ask you for data to quickly fill in the area PRIVACY ACT NOTICE The VA will not.
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