Lynne A. Valenti
Cabinet Secretary

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Below you will find the selected forms and/or publications for this order. You will need to indicate the quantity you want to receive in the box next to the document number. After you have entered the quantity, click "Update" in the previous box. If you wish to remove a form or publication, simply click on the link that states "Delete." Once you have entered the quantity for each form or publication, click the "Proceed" button at the bottom.

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CopiesEdit the Number of CopiesDocument NumberDocument NameDelete
1EditCPS-522Request for PaymentDelete
1EditEA-320Self-Employment LedgerDelete
1EditCPSProvider Mileage RequestDelete
1EditRec and FraudCasualty Settlement Report FormDelete
1EditMSTitle XIX Non-Emergency Transportation Payment Authorization FormDelete
1EditBRO/VS1Sexual Assault BrochureDelete
1EditMSHysterectomy Acknowledgement of InformationDelete
1EditBRO/DSS8Notice of Privacy BrochureDelete
1EditBRO/EA2SNAP BrochureDelete
1EditBRO/CPS1Child Protection Services BookletDelete
1EditCPSIndependent Living Program BrochureDelete
1EditPAPrior Authorization Forms: Out-of State Services Delete
1EditBRO/EA12Energy Assistance BrochureDelete
1EditCCSPathways to Professional Development - Career Lattice Application FormDelete
1EditMSProviders: NEMT Provider AgreementDelete
1EditEA-269Recipient Forms: Child Care Expense Billing InformationDelete
1EditRec and FraudStop Benefit Fraud InsertDelete
1EditEA-301MAChildren and Family Medical Assistance Supplemental Application Delete
1EditBRO/RE4Medicaid Liens BrochureDelete
1EditEA-231Recipient Forms: Child Support Enforcement ReferralDelete
1EditBH-063rd Party Release of Information (ROI)Delete
1EditBRO/DCS2Teenage Parents Guide - How to Establish Paternity and Financial Support for your ChildDelete