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LITTLE TRAVERSE BAY BANDS OF OD AWA INDIANS Purchased/Referred Care Program 1260 Hijack Avenue Pentosan, MI 49770 P: 2312421600 F: 2312421617PRESCREEN FORM For Medical Assistance Programs and Medicare

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How to fill out prescreen form

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Obtain the prescreen form from the appropriate source, such as a medical facility or research institution.

02

Carefully read through each section of the form to ensure you understand what information is required.

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Fill out the form completely and accurately, providing all requested details about yourself.

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Who needs prescreen form?

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Individuals who are seeking medical treatment or participation in a research study may be required to fill out a prescreen form.

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Employers or educational institutions may also request individuals to complete a prescreen form as part of a screening process.

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What is prescreen form?

Prescreen form is a form that collects information about individuals to determine their eligibility for a program or service.

Who is required to file prescreen form?

Individuals who wish to apply for a specific program or service are required to file a prescreen form.

How to fill out prescreen form?

To fill out a prescreen form, individuals must provide accurate information about themselves and their eligibility for the program or service.

What is the purpose of prescreen form?

The purpose of prescreen form is to gather necessary information to determine if an individual qualifies for a specific program or service.

What information must be reported on prescreen form?

The information required on a prescreen form may vary depending on the program or service, but typically includes personal details, eligibility criteria, and any supporting documentation.

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