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I hereby grant permission and authorize any accredited agent of the Medicaid program to disclose to my hospital provider ALL information regarding the status of my Medicaid application and if the application is not approved and the reason for disapproval. I will ASSIGN to my hospital provider ALL FUNDS received from the above sources which are provided to help with this HOSPITAL BILL. I on my own behalf and for my immediate family member s authorized representative s physician s counselor s...
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Chippewa Valley is a region in the Midwest United States, primarily located in Wisconsin.
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