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If you have not seen a medical provider for your impairment s within the past 12 months a consultative exam may be arranged for you by the local agency. NEW YORK STATE DEPARTMENT OF HEALTH State Disability Review Unit Disability Questionnaire COMPLETED BY THE STATE DISABILITY REVIEW UNIT NAME Case Number First Client ID Number CIN Middle Disability ID Number DIN Last Medicaid application date Social Security Number last 4 digits Medicaid Waiver Date of Birth Waiver type Yes No Telephone No Have ...

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