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CSHCS Income Review
Payment Agreement

Item#HP-M123E

    The Income Review/Payment Agreement is used to determine is a payment agreement for the enrollment fee is required of the family to receive coverage by the Children's Special Health Care Services (CSHCS) program.

    • Intended Health Department Use Only
    • Weekly order limit of 25 pieces
    • MDHHS Pub-MSA-0738 (Rev. Date 02/20)
    • 8.5" x 11" carbon copy form



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    1 $0.00

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