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Click ‘Get Form’ to open it in the editor.
Begin with SECTION A. Select the type of request that applies to your situation by checking the appropriate box. This will guide you through the relevant sections based on your choice.
Proceed to SECTION B. Fill in the Legal Entity Name, Service Location’s Address, Contact Name, Phone Number, MPI #, Email Address, and Service Location Code. Ensure all information is accurate for processing.
In SECTION C (if applicable), provide details about the Effective Date of Licensing, Licensed Capacity, and Requested APC. Describe how the needs of individuals align with your request.
If you are changing APC in SECTION D, enter Current APC and Requested Change in APC along with relevant dates. Provide a description of circumstances surrounding this change.
Review all sections for completeness before submitting your form through our platform.

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2019	4.6 Satisfied (54 Votes)

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