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If employed copies of four current consecutive paycheck stubs for patient and spouse. If Selfemployed a copy of the federal tax form schedule C. A copy of the State Assistance program decision notice. AHCCCS Medi-Cal or Medicaid. NOTE Failure to provide information or failure to participate in the interview is not acceptable and cannot be used in this application. Completing the application is not a guarantee you will be approved for the Financial Assistance Program. Approval is based on...
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