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Type of Control Zip State Telephone No - To Medicaid Provider No. a. Voluntary Nonprofit b. Proprietary 1. As Filed Provider Version -- Status X Desk Reviewed -- Revised Desk Reviewed -- Field Audited -- DEPARTMENT OF HUMAN RESOURCES - DIVISION OF MEDICAL ASSISTANCE 2016 RURAL HEALTH CLINIC 1. INTENTIONAL MISREPRESENTATION OR FALSIFICATION OF ANY INFORMATION CONTAINED IN THIS COST REPORT MAY BE PUNISHABLE BY FINE AND/OR IMPRISONMENT UNDER FEDERAL AND STATE LAW. CERTIFICATION STATEMENT I...
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