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MEDICAID HOSPICE ELECTION FORM
**INCOMPLETE FORMS CANNOT BE PROCESSED BY SCD HHS**EFFECTIVE DATE:
RECIPIENT INFORMATION:
NAME:LASTFIRSTCURRENT MAILING ADDRESS:MEDICAID ID NUMBER:STREETCAR:STATE:HOME
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What is common mistakes when submitting?
Common mistakes when submitting include incomplete forms, incorrect information, and failing to sign documents.
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To avoid common mistakes when submitting, carefully read the instructions, double-check all entries for accuracy, and ensure all required fields are completed.
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