INSTRUCTIONS FOR COMPLETING INCOME AND EXPENSE …
ME. WISCONSIN DEPARTMENT OF HEALTH SERVICES. Division of Medicaid Services. F-00295 (01/2018) MEDICAL AND REMEDIAL EXPENSES CHECKLIST FOR MEDICAID LONG-TERM CARE WAIVER PROGRAMS. Name – Member/Participant PURPOSE: This form is used to determine any medical and remedial expenses that can be used to reduce a cost share. A cost share is the monthly … ................
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