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Application for Adult Day Care
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Alone with Home Health Aide
 
  
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Advanced Directive - Patient Advocate
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Medicare Number   Effective date (MO/DD/YR)
Medicaid I.D. Number   Medicaid Case Number
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Community Village does not discriminate on the basis of race, religion, color,
national origin, sex, age, handicap, marital status or sexual orientation.
 
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