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Resident Information

Name:
Referral Date:
Facility:
Admission:
Projected Medicaid Eligibility:
*Monthly Estimated Applied Income:
*Money you owe the nursing home every month.

Allied Planning Contacts

Analyst:
Medicaid Specialist:
Need a title: Celia Ramirez | (806) 208-4611
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Date:
Activity:
Status:
Next Case Follow Up:
Application Submitted:
HHSC's Estimated Processing Due Date:
Notes:
Name:
Address:
Phone:
Email:
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