Applicant NOT Currently On The Waiver

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* 1. Name of Applicant

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* 2. Date of Birth

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* 3. Place of Birth

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* 4. Current Address

Street

City

State

Zip

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* 5. Telephone #

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* 6. Social Security #

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* 7. Medicaid #

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* 8. Additional Insurance

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* 9. Marital Status

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* 10. Gender

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* 11. Does the Applicant have a Guardian?

Yes

No