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The document is a Request for Medical Eligibility Determination, which collects detailed information about a recipient's personal details, living arrangements, previous care, and medical history. It includes sections for the attending physician to specify the required level of care, assess home/community-based services adequacy, and provide medical information such as diagnoses, medications, recent hospitalizations, mental status, activities of daily living, special care needs, and physical examination results. The document requires signatures from medical professionals to validate the information provided.

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Versions	Form popularity	Fillable & printable
2018	4.8 Satisfied (61 Votes)
2008	4.4 Satisfied (581 Votes)

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