LTC FS - Diagnosis Verification - Wisconsin
Secretary. State of . Wisconsin. DHSIRIS@dhs.wisconsin.gov. Department of Health Services. DHS/DMS F-01942A (02/2021) www.dhs.wisconsin.gov. Date. Recipient’s Name. Recipient’s Address. City, State, Zip Code. Dear Recipient’s Name, Your patient, Participant’s Name (DOB Date of Birth), receives long-term care services through Wisconsin Medicaid and Wisconsin IRIS programs. To … ................
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