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Fields will appear on the document as you type

1. Name of Applicant or Individual

Enter the full legal name as it appears on the application.

2. Medicaid ID or Social Security No.

This is printed on the applicant's Medicaid card.

3. MERP Acknowledgement

4. Printed Name — Responsible Person

The person completing this form on the applicant's behalf, if applicable.

5. Relationship to Individual (if not individual)

6. Signature

Complete the form to download