Fillable Application for Adults and Children with Long Term Care Needs

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State of Alaska Department of Health and Social Services Division of Public Assistance If known, please provide the following information: name of agency or nursing home name of care coord./ social worker Application for Adults and Children with Long Term Care Needs Please check the services you need: Home and Community-Based Services Medicaid Waiver (a.k.a. CHOICE) phone fax Child with Disabilities Nursing
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