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
1EditEA-320Self-Employment LedgerDelete
1EditBH-05Hardship Considerations RefusalDelete
1EditBRO/EA11Weatherization Assistance BrochureDelete
1EditEA-320Self-Employment LedgerDelete
1EditCPS-506Foster/Adoptive Parent Health ReportDelete
1EditEA-240Application for Resource Assessment, Long Term Care or Related Medical AssistanceDelete
1EditBRO/CCS6Child Care Assistance Program BrochureDelete
1EditBRO/EA16Medical Assistance for Children and Families: IHS SpecificDelete
1EditBRO/EA2SNAP BrochureDelete
1EditCPSIndependent Living Program Education and Training Voucher Delete
1EditPAPrior Authorization Forms: BRCADelete
1EditRec and FraudStop Benefit Fraud InsertDelete
1EditBRO/EA10SNAP for StudentsDelete
1EditBH-14Substance Abuse - Accreditation ApplicationDelete
1EditMS-103Provider Change FormDelete
1EditSE-492Notice of Shared Medical ExpensesDelete
1EditPAPrior Authorization Forms: GeneralDelete
1EditBH-11aAdult SUD Initial Outcome ToolDelete
1EditPOS/EA02Long-Term Care Partnership Fact SheetDelete
1EditSE-431AChild Support Payment Authorization FormDelete
1EditEA-297Energy Assistance ApplicationDelete
1EditBRO/EA5Medicare Savings Program BrochureDelete
1EditBH-11dAdult MH Initial Outcome ToolDelete
1EditBRO/CPS18Family Group Conferencing – Provider Guide Delete
1EditEA-307SNAP Exit FormDelete